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News ArticleThe family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
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News Article
Young autistic people still dying despite coroner warnings over care
Patient Safety Learning posted a news article in News
Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found. Their investigation found issues that were flagged a decade ago are still being warned about now. Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart. The coroner who oversaw both cases, noted a repeated failure in care. After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued. Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed. In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years. Read full story Source: BBC News, 7 September 2023 -
News Article
Man's bed death was avoidable, says coroner
Patient Safety Learning posted a news article in News
The death of a retired police officer who got his head trapped in a hospital bed was an avoidable accident, an inquest has concluded. Max Dingle, 83, of Newtown, Powys, died after he became stuck between the rails and mattress at the Royal Shrewsbury Hospital on 3 May 2020. The initial post-mortem test gave the cause of death as heart disease. But a second examination, commissioned by Mr Dingle's son, found entrapment and asphyxiation to be the cause. After comparing and discussing their findings, both pathologists then agreed "entrapment did play a significant part in the cause of death", the senior coroner for Shropshire John Ellery said. The inquest was told Mr Dingle's son Phil had asked for the second post-mortem test because "did not accept" the initial findings and had sought the opinion of a pathologist in Australia, where he lives. Max Dingle, who had been admitted to the hospital with shortness of breath, died 15 minutes after he was found to be trapped, the hearing was told. Concluding the inquest, Mr Ellery said: "Based on all the evidence, the conclusions of this inquest are Mr Dingle's death was an avoidable accident." Read full story Source: BBC News, 1 June 2022 -
News Article
Ambulance trust covered up paramedics’ fatal errors like a ‘criminal gang’
Patient Safety Learning posted a news article in News
An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up. Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown. “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.” Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police. Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public. Read full story (paywalled) Source: The Times, 29 May 2022 -
News Article
Blackpool death: Abortion sepsis risk training inadequate
Patient Safety Learning posted a news article in News
Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital. The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient. "Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added. Read full story Source: BBC News, 19 May 2022 -
News ArticleHeart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
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News Article
‘Staff holidays’ delay death review by up to nine months
Patient Safety Learning posted a news article in News
A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’. An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”. She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “care support” (a non-clinical programme for people with lower-level concerns and complexities). An earlier investigation into her death by the trust, finalised in December, said the trust should audit other cases to check whether the trust’s 2019 “care management and CPA/care support policy” was being complied with. Now Birmingham and Solihull coroner James Bennett has criticised a delay in carrying out the trust-wide audit – writing in a prevention of future deaths report that, as of last month, four months after the report investigating Ms Adams’ care was completed, “no action has been taken”. Read full story (paywalled) Source: HSJ, 5 May 2022 -
News Article
‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery
Patient Safety Learning posted a news article in News
"I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes. Eight weeks later, Brooke took her own life. The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died. In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders. After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch. But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital. After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge. It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards. Read full story Source: The Guardian, 24 April 2022 -
News Article
Care home resident died after unqualified nurse administered wrong medication
Patient Safety Learning posted a news article in News
A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake. Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard. She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported . Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any qualifications. She gave Miss Thorne clozapine, which had been intended for another resident, on October 6, 2010. Instead of owning up to what she did, Ms Hutchinson then tried to cover up her mistake by taking Miss Thorne to bed and leaving her there until she was discovered, Senior Coroner Dr Robert Hunter said. Miss Thorne was "found by the care support worker around midnight, when undertaking routine checks on residents”, the inquest heard. And then Ms Hutchinson’s mistake was only discovered after an audit was carried out of the medication trolley and a dosage of clozapine was found. Read full story Source: Mirror, 8 April 2022 -
News Article
NHS trust apologises over death of woman, 27, after cancer misdiagnosis
Patient Safety Learning posted a news article in News
An NHS trust has apologised over the death of a 27-year-old events manager after a locum gynaecologist mistook aggressive cervical cancer for a hormonal or bowel problem. The family of Porsche McGregor-Sims, who died a day after being admitted to Queen Alexandra hospital in Portsmouth, told her inquest that she had felt she was not listened to and that the misdiagnosis had robbed them of a chance to say goodbye. The area coroner Rosamund Rhodes-Kemp said the case was one of the most “shocking and traumatic” she had dealt with and she would write to Portsmouth hospitals university NHS trust expressing her concern. In December 2019, McGregor-Sims’ GP referred her to a consultant after she complained of abdominal pain and vaginal bleeding. She saw Dr Peter Schlesinger, an agency locum at the Queen Alexandra hospital, at the end of January 2020. He did not physically examine her and believed her symptoms were linked to changing hormones or irritable bowel syndrome (IBS). After the UK went into lockdown two months later, McGregor-Sims continued to report symptoms but was prescribed antibiotics over the phone and was seen in person only after a GP thought she might have Covid because she had shortness of breath. McGregor-Sims was finally diagnosed with an aggressive form of cervical cancer and on 13 April was taken to hospital, where she died a day later. During the inquest, her family accused Schlesinger of having denied them their chance to say goodbye. Her mother, Fiona Hawke, told him: “You robbed us of the opportunity to prepare for her death and say goodbye to her.” Schlesinger insisted McGregor-Sims’ symptoms – including bleeding after sex – did not lead him to think she had a serious illness. Dr Claire Burton, a consultant gynaecologist, said Schlesinger should have physically examined McGregor-Sims, and apologised for the care she received at the trust. Read full story Source: The Guardian, 24 March 2022 -
News Article
Transgender teenager's death preventable, coroner says
Patient Safety Learning posted a news article in News
The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022 -
News Article
Man's partner 'begged' for help before his death
Patient Safety Learning posted a news article in News
A man who died from a mixed medication overdose might still be alive if the help his partner was "begging" for had been provided, a coroner said. Mental health patient Benjamin Stroud, 42, had been under the care of Essex Partnership University NHS Trust (EPUT) in the weeks before his death in March. Essex coroner Michelle Brown said in a post-inquest report that, despite "escalating psychosis", his care co-ordinator did not flag the case. Following an overdose of medication in February, his partner, a nurse, called for psychiatric intervention and despite "begging" for help, Mr Stroud's care co-ordinator did not make a referral to the multi-disciplinary team (MDT). Mr Stroud died at home on 19 March and was found surrounded by empty insulin pens and pain medication. In her prevention of future deaths report, the coroner said: "It was clear from [his partner's] account that she had been begging the care co-ordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur and, from the evidence of EPUT, it was clear that Mr Stroud's care co-ordinator did not make any referral to the MDT, despite his escalating psychosis." The coroner added that the issue of care co-ordinators failing to document their reasons for not referring cases to the MDT had been raised at other inquests. "If these practices continue there is a real risk of future deaths occurring," Ms Brown warned. Paul Scott, chief executive at the trust, said: "We will continue to view all safety-related incidents as an opportunity to learn and make sure lessons are shared across the trust." Read full story Source: BBC News, 16 February 2022 -
News ArticleMedical neglect and “gross failures” by a mental health trust contributed to the suicide of a 12-year-old girl in a case that has highlighted national concerns about underfunding, a coroner has ruled. Allison Aules from Redbridge, in north-east London, died in July last year after her mood changed completely during the Covid lockdown, her family told the inquest at an east London coroner’s court. At the conclusion of the inquest, the area coroner Nadia Persaud highlighted a series of failures by North East London NHS foundation trust (NELFT) that contributed to her death. In a narrative verdict she ruled it was a “suicide contributed to by neglect”. Persaud also said failures in Allison’s care raised wider national issues about under-resourcing and “outstanding concerns” about the lack of consultant psychiatrists. These will be addressed later in a prevention of future deaths report. Persaud told the court: “There are national concerns around children and adolescent mental health services … and I’m also going to write a report at the national level to reduce the risk of this happening again.” Persaud said Allison’s case showed “both operational failures of individual practitioners and systemic failings on behalf of the trust”. She added: “This was on a backdrop of a very under-resourced service.” Read full story Source: The Guardian, 17 August 2023
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News Article
Coroners issue 24 warnings over emergency care crisis
Patient_Safety_Learning posted a news article in News
Coroners have warned of increasing numbers of deaths caused by problems in the emergency pathway, with some citing ‘severe’ staffing shortages. HSJ has identified that at least 24 “prevention of future death” reports were sent to NHS organisations in England and Wales in the first half of 2023, which noted shortcomings within emergency services. In six of the 24 cases, coroners found ambulance, emergency room and other delays caused or contributed to patient deaths. Read full story Source: HSJ 1 August 2023 -
News Article
‘Serious failings’ contributed to baby’s death in 12-hour lone prison birth
Patient Safety Learning posted a news article in News
Serious systemic failings contributed to the death of a newborn baby in a cell at Europe’s largest women’s prison, a coroner has concluded. Rianna Cleary, who was 18 at the time, gave birth to her daughter Aisha alone in her prison cell at HMP Bronzefield, in Surrey, on the night of 26 September 2019. The care-leaver was on remand awaiting sentence after pleading guilty to a robbery charge. The inquest into the baby’s death heard that Cleary’s calls for help when she was in labour were ignored, she was left alone in her cell for 12 hours and bit through the umbilical cord to cut it. In a devastating witness statement read to the court, Cleary described going into labour alone as “the worst and most terrifying and degrading experience of my life”. She said: “I didn’t know when I was due to give birth. I was in really serious pain. I went to the buzzer and asked for a nurse or an ambulance twice.” Cleary passed out and when she woke up she had given birth. The senior coroner for Surrey, Richard Travers, said Aisha “arrived into the world in the most harrowing of circumstances”. He concluded it was “unascertained” whether she was born alive and died shortly after or was stillborn. Read full story Source: The Guardian, 28 July 2023 -
News ArticleMinisters are backing a potentially “dangerous” new model allowing police to reduce their response to mental health incidents after failing to formally assess the risk of harm or death. Officials are monitoring any “adverse incomes” from the National Partnership Agreement, which will see police forces stop attending health calls unless there is a safety risk or a crime being committed. Policing minister Chris Philp said a pilot by Humberside Police gave him confidence in national roll-out, which aims to “make sure that people suffering mental health crisis get a health response and not a police response”. Mental health charities and experts have warned the plans could be “dangerous”, and a coroner raised the alarm following a woman’s suicide after police failed to respond to her disappearance. A report published last month said action was needed to prevent future deaths, warning that the new model could “allow each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient”. Read full story Source: The Independent, 26 July 2023
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News Article
NHS trust accused of cover-up is refusing to release report into deaths
Patient Safety Learning posted a news article in News
An ambulance trust accused of hiding information from a coroner about patients that died is keeping a damning internal report about the deaths secret, the Guardian can reveal. A consultant paramedic implicated in the alleged cover-ups continues to be involved in decisions to keep the report from the public. Earlier this month, North East Ambulance Service (NEAS) apologised to relatives after a review into claims it covered up errors by paramedics and withheld evidence from the local coroner about the deceased patients. But a bereaved family left in the dark about mistakes made before their daughter’s death have rejected the apology. Now, it has emerged that a 2020 internal interim report on the alleged cover-up continues to be kept secret by the trust. The damning report by consultants AuditOne has been leaked to the Guardian after first being exposed by the Sunday Times. Paul Aitken-Fell, a consultant paramedic blamed in the report for amending information sent to the coroner and removing crucial passages about mistakes by the trust’s paramedics, remains in post. He also holds the gatekeeper role of FoI review officer, and as such has endorsed decisions to refuse to release the report to members of the public who ask for it. Read full story Source: The Guardian, 24 July 2023 -
News Article
NHS trust criticised over deaths of new mothers from herpes
Patient Safety Learning posted a news article in News
A coroner has criticised an NHS trust over the deaths of two new mothers with herpes. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died in 2018 after having caesarean sections six weeks apart by the same surgeon at hospitals in Kent. Their families have been waiting five years for answers on how they came to be infected with the virus, which can cause sores around the mouth or genitals. Catherine Wood, Mid Kent and Medway coroner, said Sampson could have been given an anti-viral treatment sooner. Wood added that in Mulcahy’s case “suspicion should have been raised” given the knowledge among staff from Sampson’s earlier death. The coroner ruled out human culpability of any of the medical staff involved in the case and said it was “unlikely” for the surgeon to be the cause of the herpes infection found in both women. Read full story Source: The Guardian, 14 July 2023 -
News Article
Baby died of brain injury after midwives ‘neglected’ mum while breastfeeding
Patient Safety Learning posted a news article in News
Olly Vickers died of a brain injury in February last year just weeks after two midwives at Royal Bolton Hospital let his mother Emma Clark feed him while she was having gas and air – in breach of guidelines. Despite being well when he was born, Olly was found “pale and floppy” hours later due to his airways being obstructed. He developed a brain injury and died five months later. Coroner Peter Sigee ruled his death was a result of “neglect” and due to a “gross failure to provide basic medical care”. An inquest into his death heard a student midwife placed a pillow under his mother’s arm while she was feeding him, “contrary to accepted practice”. Another midwife then gave Ms Clark gas and air while she was feeding Olly as she was stitched up for a tear obtained during labour – which again went against guidance. No risk assessment was carried out and the coroner said Olly’s breastfeeding should have been stopped before the midwives began to suture Ms Clark. Read full story Source: The Independent, 8 July 2023 -
News Article
Paramedic in fatal crash had traumatic flashback
Patient Safety Learning posted a news article in News
A paramedic was hallucinating after a traumatic call-out when he crashed into a car, an inquest heard. Jason Allen, 49, and Andrew Ralph, 61, were killed after their car was hit by Kevin Lilwall's ambulance on the A49 in Pengethley, Herefordshire. An inquest heard Mr Lilwall was having flashbacks to the previous day when he had been in the area responding to the sudden death of a baby. The paramedic, who had worked for West Midlands Ambulance Service (WMAS) for 28 years, was driving the ambulance when it crossed the white line into the car. The ambulance dashcam showed it heading directly towards Mr Allen’s car for six seconds before the collision. The families of Mr Allen and Mr Ralph said they had been through hell in the past four years, adding they had never had an apology from Mr Lilwall and only one from WMAS after the inquest. The hearing in Hereford was told Mr Lilwall had spent more than 25 hours on duty in the previous 36 hours, with just a 10-hour break between shifts. Medical experts agreed that the hallucination could have been caused by post traumatic stress disorder. Jason Wiles from WMAS admitted it had been a "missed opportunity" regarding the apology and said it had changed its policy to ensure staff had a break of at least 11 hours between shifts following the crash. Read full story Source: BBC News, 28 June 2023 -
News Article
Bereaved call for body to enforce coroners’ advice
Patient Safety Learning posted a news article in News
Relatives of a teenage rape survivor who died after failures by mental health services are joining other families to demand a new body to enforce coroners’ recommendations to prevent future deaths. Campaigners claim the failure to act on hundreds of coroners’ recommendations every year, and to learn from the findings of often expensive inquiries into disasters, means the same mistakes are being repeated. Gaia Pope, 19, was diagnosed with post-traumatic stress disorder after revealing that she had been drugged and raped when she was 16. She was found dead in undergrowth on a cliff 11 days after disappearing in Swanage, Dorset, in 2017. After one of the longest inquests in legal history, the coroner, Rachael Griffin, made multiple reports last year to authorities including the NHS and police to prevent future deaths, but Pope’s family says most have not been acted upon. The Inquest campaign, which works with families bereaved by state-related deaths, is calling for a “national oversight mechanism” to collate recommendations and responses in a new national database, analyse responses from public bodies, follow up on progress and share common findings. Read full story (paywalled) Source: The Times, 27 June 2023 -
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Coroner issues warning on NHS mental health services after girl’s suicide
Patient Safety Learning posted a news article in News
A coroner has said Britain is failing young people and more will die because of under-resourced mental health services, as she ruled that neglect led to the death of a 14-year-old girl. Penelope Schofield, the senior coroner for West Sussex, said she would write to the health secretary, Sajid Javid, to raise concerns after the case of Robyn Skilton, who killed herself after being let down by “gross failures” in NHS mental health services. Robyn, from Horsham in West Sussex, disappeared from her family home and took her own life in a park on 7 May last year, her inquest in Chichester heard. Despite serious concerns about her mental health, Robyn did not get face-to-face consultations, was not seen by a child psychiatrist or assessed for mental health issues, and was discharged from an NHS service a month before her suicide though she was on its high-risk “red list”. Her father, Alan Skilton, told the inquest he pleaded for help, and he described the lack of care his daughter received as “astonishing”. He said he believed that if Robyn had been seen earlier, her mental health would have improved and she would not have killed herself. The coroner said: “As a society we are failing young people.” She said she was shocked to hear that the number of young people seeking mental health help had increased by 95%. “Trying to manage it without more resources means we are not providing the help that young people need. Robyn’s case is a testament to that. It’s a clear risk that more lives will be lost if we don’t address it.” Read full story Source: The Guardian, 29 June 2022 -
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Birmingham hospital faces criminal probe after death of vulnerable man
Patient Safety Learning posted a news article in News
A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022 -
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Trust failed for months to give vital medication to vulnerable inmate
Patient Safety Learning posted a news article in News
A troubled NHS trust failed for months to give vital medication to a prison inmate who had a long-standing diagnosis of HIV, an inquest has found. A jury at Essex Coroner’s Court concluded that a series of failures and neglect by Essex Partnership University Trust (EPUT) contributed to the death of Thokozani Shiri in April 2019. The 21-year-old spent two spells as a prisoner at HMP Chelmsford, where EPUT provided some services at the time. He was considered vulnerable due to a long-standing diagnosis of HIV for which he was receiving treatment before he went to prison, and the trust was aware he had HIV throughout both stays, the inquest heard. The inquest jury identified that five separate failings had “probably caused” Mr Shiri’s death. These included: a failure to provide antiretroviral medication to Mr Shiri during both periods of imprisonment; a failure to refer him to an HIV clinic; the absence of an appropriate care plan and engagement with a multidisciplinary team; and inadequate management of records. Each failing on behalf of the trust was considered by the jury to have amounted to neglect. Read full story (paywalled) Source: HSJ, 9 June 2022 -
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'Unprecedented': Coroner prohibits naming of surgeon in herpes deaths inquest
Patient Safety Learning posted a news article in News
A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling. Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health. Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT). On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports. Read full story Source: Medscape, 9 March 2023
