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News Article
Coroner says student might be alive if GP had seen him
Patient Safety Learning posted a news article in News
A law student who died after four remote GP consultations might have lived had he been given a face-to-face appointment, a coroner ruled. David Nash, 26, died in November 2020 from a bone infection behind his ear that caused an abscess on the brain. Over a 19-day period leading up to his death, he had four phone consultations with his GP. The coroner, Abigail Combes, said the failure to see him meant he underwent surgery ten hours later than it could have been. Andrew and Anne Nash fought for more than two years to find out whether their son would have lived if he had been seen in person by clinical staff at Burley Park Medical Centre in Leeds. Yesterday they said they were “both saddened and vindicated by the findings that the simple and obvious, necessary step of seeing him in person would have saved his life” and wanted to make sure “others don’t die as David did”. Read full story (paywalled) Source: The Times, 21 January 2023 -
News ArticleAn NHS trust declined to provide care for a vulnerable Black man days before he died in police custody while having a psychotic episode, The Independent has learnt. Godrick Osei, 35, died after being restrained by up to seven Devon and Cornwall Police officers in the early hours of 3 July 2022, after fleeing his flat and hiding in the cupboard of a care home in Truro. His family said he had been expressing “paranoid thoughts” and had called the police himself for help. He was arrested and died within an hour. Mr Osei had been diagnosed with anxiety and depression, had suspected post-traumatic stress disorder (PTSD) and was prescribed various medications to treat these conditions. He also intermittently used illicit drugs and had suffered alleged sexual assault in prison around 2013, according to a medical report from North East London NHS Foundation Trust (NELFT). In the days before his death, Mr Osei was in the care of NELFT’s community mental health team, whose caseworkers were concerned that he was exhibiting signs of a further severe illness – emotionally unstable personality disorder (EUPD) – and was a high risk to himself. However, Mr Osei was based outside the team’s catchment area, and NELFT asked the neighbouring Cornwall Partnership NHS Foundation Trust (CPT) to assess him instead. CPT refused without explaining why, according to a medical report seen by The Independent. Following Mr Osei’s death, an investigating officer from NELFT made multiple attempts to contact CPT to explore the possibility of a joint investigation into the matter, but didn’t receive a response. Read full story Source: The Independent, 16 January 2023
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News Article
Wales coroner rules nurses’ Covid deaths as industrial disease
Patient Safety Learning posted a news article in News
The deaths of two nurses from Covid-19 in the early days of the pandemic have been ruled as industrial disease. Gareth Roberts, 65, of Aberdare, and Domingo David, 63, of Penarth, were found to have been most likely to have contracted the virus from colleagues or patients while working for hospitals under the Cardiff and Vale University Health Board. The senior coroner Graeme Hughes concluded on Friday that although they were given appropriate personal protective equipment (PPE), Roberts and David were “exposed to Covid-19 infection at work, became infected and that infection caused” their deaths. He made a finding of industrial disease. Roberts’ family had argued for a conclusion of industrial disease, while the health board had made the case for ruling that both deaths were from natural causes. Unions are campaigning for Covid-19 to be considered an industrial disease by the UK government so workers affected by it would receive greater financial support. Read full story Source: The Guardian, 13 January 2023 -
News ArticleA warning has been made over the possible side effects of a common NHS antibiotic by a coroner after a newly retired senior doctor died by suicide. "Respected and experienced" consultant cardiologist Robert Stevenson had no history of depression or mental health problems before he started a course of ciprofloxacin. But just over a week later, the 63-year-old went for a walk and messaged his wife to tell her he had left a note under his pillow. He was later found dead in a nearby wood. The note he had left was said to be "uncharacteristically confused and illogical" with "baseless concerns" that he might have AIDS after taking an online HIV tester kit, an inquest heard. The hearing was told Dr Stevenson hadn't been told about a "potential rare link" to suicidal behaviour in patients who took the drug, as this wasn't in line with medical guidance. Now, coroner Martin Fleming issued a warning to highlight the risk of taking the antibiotic, which is prescribed by the health service for serious conditions. Read full story Source: The Mirror, 20 June 2023
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News Article
New triage policy implicated in 44-year-old’s death
Patient Safety Learning posted a news article in News
An ambulance service says it has sped up clinical review of lower-priority calls, after a coroner said the new triage process — introduced in response to recent waiting time pressures — ‘will lead to further deaths’. The coroner raised concerns with West Midlands Ambulance Service after a type 1 diabetic patient died following a long delay in deciding whether to send an ambulance. Following a pilot in July 2021, all category 3 and 4 incidents at WMAS, except for a predefined list of exceptions, are sent directly to the trust’s “clinical validation team” to triage patients, with the aim of reducing the need for ambulance call-outs. It is thought a similar approach has been introduced across England since covid, as there have been huge pressures on ambulance capacity. But coroner Emma Serrano has raised concerns about the process in a prevention of future deaths report published this week. The inquest was told that Ms Finch waited 10 hours for her call to be “clinically assessed” and an ambulance call-out approved as the validation team was “under-staffed”. The PFD report also said that there was “no time limit” for assessments to take place, and no prioritisation system. Read full story (paywalled) Source: HSJ, 14 June 2023 -
News Article
Health officials ‘ignored evidence of non-Covid deaths’ during lockdown
Patient Safety Learning posted a news article in News
The Covid inquiry is being urged to investigate if health officials dismissed evidence of collateral deaths during lockdown after a whistleblower claimed that pathologists’ concerns were shut down. As the inquiry prepares to hold its first full public hearing this week, Prof Sebastian Lucas, who worked as a consultant pathologist at St Thomas’ Hospital in London, claimed that PHE was not interested in what he described as “collateral deaths”. Prof Lucas wrote to Prof Kevin Fenton, the director of PHE London, on behalf of the London Inner South Jurisdiction Pathology Advisory Group. He approached the agency in January 2021 as the UK entered its third lockdown, warning that collateral deaths as a result of the pandemic had not been recorded properly. The group, which was headed up by a coroner, had identified several deaths that would not have happened had the NHS been functioning as normal. This included people who did not want to bother the doctor or who took their own lives because of lockdowns. Read full story (paywalled) Source: The Telegraph, 10 June 2023 -
News Article
Child died at mental health hospital ‘while staff were meant to be watching her’
Patient Safety Learning posted a news article in News
A 14-year-old girl who should have been under constant supervision at a mental health hospital died after a member of staff on his first shift left her unattended, an inquest has heard. Ruth Szymankiewicz died at Taplow Manor Hospital in Maidenhead on 12 February 2022 after a care worker responsible for her one-to-one supervision “sporadically” left his post, the hearing was told. It also emerged at the hearing that the care worker, who is now abroad, was allegedly using a fake name. Detectives are investigating him as part of a fraud investigation although he has not yet been interviewed by police. After Ruth’s death, the Care Quality Commission launched a criminal investigation. In an update to the coroner, it said that the investigation was looking at whether the provider had “brought about avoidable harm or exposure to risk” in relation to the young girl’s death. Read full story Source: The Independent, 26 May 2023 -
News Article
Coroner calls for allergies tsar after 17-year-old dies from anaesthetic reaction
Patient Safety Learning posted a news article in News
A senior coroner has warned that more allergy sufferers will die due to a “lack of national leadership” following the death of a 17-year-old aspiring doctor. Heidi Connor said the “tragic” case of Alexandra Briess was “not new territory”, citing three recent cases where people had died from anaphylaxis. She has now written to the Government saying lives are at risk without better funding and research into the condition and calling for the appointment of an allergies tsar. The Berkshire coroner’s warning comes after an inquest into the death of “bright and well loved” Alexandra, who died from a reaction to a common anaesthetic. Read full story (paywalled) Source: The Times, 18 April 2023 -
News Article
Febrile seizures: Health bodies called to take action to prevent child deaths
Patient Safety Learning posted a news article in News
An inquest report into the death of a young boy who died at home in his sleep has called for health bodies to take action to prevent further deaths. Louis Rogers' death was initially categorised as Sudden Unexplained Death in Childhood (SUDC) but the report recorded febrile seizures contributed. The recommendations include: A greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures Referrals for assessment of febrile seizures should be undertaken earlier to exclude more severe underlying illnesses The NHS website and pamphlet given to parents and guardians following a child's febrile seizure should be updated to help assist them in picking up potential early indicators of a more severe illness "Robust national guidance" and education should be given to GPs so that timely referrals could be made A checklist should be provided for health practitioners so that a child was not given a misdiagnosis of a febrile seizure Records of all contact with health practitioners - including GPs and paramedics - should be available for all The recommendations were made to six health authorities: Royal College of Paediatricians, Joint Royal Colleges Ambulance Liaison Committee, National Institute for Health and Care Excellence (NICE), Royal College of General Practice, Royal College of Emergency Medicine and NHS England. Read full story Source: BBC News, 29 March 2023 -
News Article
Man died of sepsis after being sent home from Milton Keynes Hospital A&E
Patient Safety Learning posted a news article in News
A father-of-two died of sepsis three days after being sent home from A&E with antibiotics for a suspected urinary tract infection, an inquest heard. Alex Blewitt, 48, died in July 2022 after suffering a cardiac arrest caused by a perforated bowel and sepsis. Senior coroner for Milton Keynes, Dr Sean Cummings, said Mr Blewitt's death was avoidable. The coroner recorded a narrative conclusion and said he intended to issue a prevention of future deaths report. Mr Cummings said: "The doctor, who saw and assessed Mr Blewitt in the emergency department, did not read the Urgent Care Centre communication that was provided and did not record important factual information in the clinical note. "Mr Blewitt was discharged, but returned two days later when suffering with sepsis due to a previously undiagnosed bowel perforation." Mr Blewitt's widow, Amy Blewitt, said: "Alex was in such pain and kept asking the hospital for help, but they sent him home. "My plea to the hospital is please, please don't let this type of mistake ever happen to anyone else ever again." Read full story Source: BBC News, 22 March 2023 -
Content ArticleOn 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the ambulance navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind’s condition continued to deteriorate and she died at 17.52 hours.
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Content ArticleThis prevention of future deaths report looks at the death of Ben King, who died of acute respiratory failure, obesity hypoventilation syndrome and use of sedative medication. Ben had Down's Syndrome and obstructive sleep apnoea and had been detained under the Mental Health Act at Jeesal Cawston Park (JCP) from 2018. Ben’s weight as at June 2019 was recorded at 85.2 kg which had risen to 106 kg by June 2020. He was given the sedative Promethazine after becoming agitated and found unresponsive on 29 July 2020. He died later that day at Norfolk and Norwich University Hospital.
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Content ArticleThis report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
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Content ArticleOn the 5 February 2020 an inquest was opened into the death of Hayley Smith. The jury concluded on 9 March 2022 with a narrative conclusion “The deceased died from complications of anorexia nervosa.” Hayley had developed severe and enduring anorexia nervosa at around the age of nine or ten and was resistant to treatment including several hospital admissions both voluntary, and at times compulsory treatment under the Mental Health Act. She was repeatedly admitted to hospital. On the 23 December 2019 Hayley had not eaten, became confused and unwell, and an ambulance was called. The correct emergency treatment was provided but Hayley responded quickly and regained consciousness and refused further treatment or admission to hospital. On 24 December she became unwell again and this time was taken to Queen Elizabeth the Queen Mother hospital where she again refused treatment and discharged herself against medical advice. The responsible medical officer from the Kent Eating disorder team gave evidence that had the team known of either of these episodes they would have taken steps to admit her and treat her.] On Christmas Day 2019 she collapsed for a final time and this time, had an out of hospital cardiac arrest, and was admitted to Queen Elizabeth the Queen Mother hospital and transferred to Intensive care where she was diagnosed as suffering from hypoxic brain damage as a result of her cardiac arrest due to severe hypoglycaemia as a consequence of her Anorexia Nervosa. She died on 29 December 2019 at the age of 27.
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Content ArticleOn the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost
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Content ArticleCelia Marsh died on 27 December 2017 at Royal United Hospital, Bath. She had a known allergy to milk. On that day whilst in Bath City Centre she ate a super veg rainbow flatbread which she believed was safe to eat; she suffered an anaphylaxis reaction caused by milk protein which was in an ingredient within the wrap; this caused her to collapse and despite the efforts of the medical teams The medical cause of death was 1a) Anaphylaxis triggered by the consumption of milk protein.
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Content ArticleThis is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
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News ArticleA key national policy change recommended by the inquest which led to the East Kent maternity inquiry will not be implemented until next February – more than three years after it was called for by a coroner. The recommendation – that obstetric locum doctors be required to demonstrate more experience before working – was made in a prevention of future deaths report following the inquest into the death of seven-day-old Harry Richford at East Kent Hospitals University Foundation Trust. The remaining 18 recommendations from the PFD report were requiring specific actions by the trust, rather than national policy makers. The trust says they have been implemented. However, NHS England and the Royal College of Obstetricians and Gynaecologists have only in recent months produced guidance on using short-term locums in these services, and it will not come into effect until February. When it does, it will require them to complete a certification of eligibility, demonstrating they have had recent experience in a number of clinical situations, including complex Caesarean sections. Middle-grade locums have until next February to gain the certificate. The independent inquiry into maternity at the trust – prompted by Harry’s death – will report tomorrrow, Wednesday 19 October, and is expected to be highly critical of the trust, and of national efforts to make services safe over recent years. Read full story (paywalled) Source: 18 October 2022
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News Article
Coroner warns of lack of change since man's death
Patient Safety Learning posted a news article in News
A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward. Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later. In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death." She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities. These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift. Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said. Read full story Source: BBC News, 6 October 2022 -
News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, won a high court battle in December to hear details of an informal chat outside the building between Laura Elliot, a community mental health nurse who was supporting Mays, and the consultant psychiatrist Dr Kwame Fofie, which only later came to light. This was ruled to be “neither a clinical conversation nor an attempt to escalate her care” by senior coroner Prof Paul Marks on Wednesday. He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.” But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.” The Mays have spent the last seven years fighting to hear details of the car park conversation, which could have changed their understanding of what happened before their daughter died. Angela Mays added: “I never considered myself to be a campaigner. I have only considered myself to be a mother who actually wants the truth about the facts relating to her daughter’s death.” Read full story Source: The Guardian, 28 September 2022 -
News Article
Hospital rated ‘inadequate’ after death prompts inspection
Patient Safety Learning posted a news article in News
A private hospital has been rated ‘inadequate’ by a health watchdog following an inspection prompted by a young patient’s preventable death. Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May. The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020. Mr Caseby had been detained under the Mental Health Act but managed to escape Woodbourne and died after being struck by a train. Earlier this year, an inquest concluded his death was contributed to by neglect on behalf of the hospital. In April, Birmingham and Solihull coroner Louise Hunt flagged urgent concerns about record keeping, risk assessments and security of courtyard fences with Priory Group and the Department of Health and Social Care. Read full story (paywalled) Source: HSJ, 22 September 2022 -
News Article
Lawyers warned trust that staff could ‘pick and choose’ documents for coroners
Patient Safety Learning posted a news article in News
An ambulance trust accused of withholding key evidence from coroners was previously warned its staff needed training to ‘understand the real risk of committing criminal offences’ in relation to inquests into patient deaths. North East Ambulance Service, which has been accused by whistleblowers of withholding details from coroners in more than 90 deaths, was told by its lawyers in 2019 about serious shortcomings in its processes for disclosing information, according to internal documents obtained by a campaigner. According to the documents, the lawyers said trust staff could “pick and choose” documents to release to coroners “regardless of relevance.” The following year, an audit report said the issues had not been addressed. Whistleblowers’ concerns about the trust were first reported by The Sunday Times in the spring, with a review highlighting several cases between 2018 and 2019 where key facts were omitted in disclosures to coroners. But campaigner Minh Alexander has since obtained new details of warnings that were being made to internally, from lawyers and auditors who were advising the trust. Read full story Source: HSJ, 20 September 2022 -
News ArticleA coroner has said she does not understand why frontline workers were not required to wear a mask during lockdown after hearing a paramedic had died with Covid. A two-day inquest into the death of Peter Hart, who died on his 52nd birthday, concluded on Tuesday (September 13) with assistant coroner Dr Karen Henderson ruling the father-of-three died of natural causes caused by Covid. She said on the balance of probabilities he caught the disease while working at East Surrey Hospital, where he died on May 12, 2020. During the onset of the pandemic only healthcare workers tending to those suspected of having Covid-19 were required to wear personal protective equipment (PPE). In accordance with national guidelines, Mr Hart, who was treating patients not suspected of having the virus, did not need to. “Retrospectively it is difficult to comprehend why the national guidance said PPE did not need to be used for all patients and healthcare workers at the earliest opportunity,” Dr Henderson said. “Although there appears a lost opportunity to ensure maximum protection I make no finding of fact whether this contributed to Mr Hart’s death. “Patients not suspected to have Covid were not expected to wear face masks. This is in effect a perfect storm and given evidence of Mrs Hart I am satisfied Mr Hart contracted Covid during his work at East Surrey Hospital,” she added. Read full story Source: Surrey Live, 13 September 2022
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Content ArticleOn 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
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Content ArticleThis blog by Dr Georgia Richards looks at the system of learning from preventable deaths in the UK. She highlights that following the publication of a Prevention of Future Deaths report (PFD), there is no system in place to ensure responses are received and actions are taken. She then describes how the Preventable Deaths Tracker collects information from PFDs to screen and analyse preventable deaths, so that lessons can be learnt
