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Found 195 results
  1. Content Article
    This article tells the story of Stuart, who died as a result of medication errors while recovering from surgery at a private hospital in January 2013. Stuart had dystonia, an incurable condition that he managed by taking a careful balance of three medications. Following surgery to remove his larynx, the private neurological centre where he was staying ran out of clonazepam, a medication Stuart needed to control his dystonia. Stuart became very unwell, but instead of seeking advice from a doctor, the nurses treated his symptoms as a UTI. on 26 December he was found unresponsive in bed and rushed to ICU at a local hospital. but died a few weeks later from sever kidney and muscle damage. An inquest into Stuart's death found that the lack of clonazepam had caused an increase in Stuart’s muscle spasms, eventually leading to severe muscle and kidney damage. He then developed bronchopneumonia, which was the final factor in his death.
  2. Content Article
    This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control.
  3. Content Article
    This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation.
  4. Content Article
    On 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00.  The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
  5. Content Article
    On 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was: His medical cause of death was: 1a Hypoxic ischaemic brain injury 1b out of hospital cardiac arrest 1c displaced tracheal tube (trachael tube dependant) II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker). Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn.
  6. Event
    until
    This Royal Society of Medicine meeting will focus on some of the key medico-legal issues that impact GPs, primary care and patient safety, with a specific emphasis on inquests, clinical negligence and incidents. This comprehensive programme will review and explore the latest legal and regulatory developments from national leaders in each of these fields. Delegates will gain an understanding of: The role of coroners and inquests, what to expect and what GPs and those working in primary care need to do to prepare and actively learn from deaths. The role of Medical Examiners and how they will impact on primary care. The support, including education and training, available to GPs in dealing with medico-legal issues and how to access practical support (e.g. via the Medical Defence Organisations) when necessary. The role of NHS Resolution and the Clinical Negligence Scheme for GPs (CNSGP) and their impact upon GPs and patient safety. Developments in learning from incidents in primary care, including feedback from the CQC regarding best practice and areas for improvement. Book here
  7. Content Article
    A report by Fiona Ritchie OBE, Chair on behalf of Oliver’s Independent Panel for NHS England and NHS Improvement, has been published following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s Learning Disability Mortality Review (LeDeR) review into the death of Oliver McGowan.
  8. Content Article
    People are given this Guide when someone close to them has died and their death has been reported to the coroner or if they have been called as a witness at an inquest. The coroner is involved in the death because the coroner needs to make enquiries to find out what happened and how the person died. For most people, the inquest process is new. Preparing for an inquest can be difficult, and some find it hard to find their way through the legal processes on top of the distress caused by the death. This guide, from the Ministry of Justice, is designed to help bereaved families understand the coroner process.
  9. Content Article
    Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This is a coroner's report into the death of Susan Warby. The coroner's report concluded that the incorrect intravenous fluid was given and remained in place for approximately 36 hours before it was changed. As a direct result, blood tests on samples drawn from the arterial line gave incorrect results. The incorrect results were exacerbated by the poor technique being used by staff to draw blood from the arterial line transducer set when they failed to fully account for the 'dead space', which needed to be fully removed to obtain an accurate result. These erroneous blood results led to Sue being given doses of insulin medication over a two-day period that she did not need. The incorrect insulin doses caused Sue to suffer from bouts of extremely low blood sugar (hypoglycaemia) which caused her to develop a brain injury of uncertain severity.
  10. Content Article
    The case contains useful guidance for practitioners, healthcare providers and commissioners concerning when an inquest into the death of a vulnerable person at a care home will engage Article 2 ECHR.
  11. Content Article
    This case will be of interest to capacity assessors, practitioners, healthcare providers and commissioners because it provides further guidance on the Court of Protection’s approach to capacity and best interests in relation to clinically assisted nutrition and hydration for victims of abuse and trauma.
  12. Content Article
    What can we take from the steady flow of Prevention of Future Deaths Reports (PFDs) issued by coroners in relation to patient care? How do these fit into the wider learning from deaths landscape? To help answer these questions, international law business DAC Beachcroft have taken a closer look at hospital-related PFDs to see if any common themes emerge and, if so, what is in the pipeline for tackling them.
  13. Content Article
    Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This is a coroner's report into the death of 35 year-old Mr Mitica Marin. It was found that the defibrillator was set to manual mode, which  meant that staff were not automatically alerted to the fact that Mitica's heart had a shockable rhythm. This caused a delay to Mr Marin receiving CPR treatment.
  14. Content Article
    Coroners have a statutory duty to issue a Prevention of Further Deaths report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.  This coroners report relates to the death of 15 year-old Najeeb Katende and the delay in defibrillation due to the equipment being set to manual mode and not detecting his shockable rhythm. The coroner found that the delay in defibrillating Najeeb significantly reduced his chances of survival.
  15. Content Article
    Joanna is a Partner in the law firm Bevan Brittan LLP. In our interview, Joanna talks about her role supporting healthcare staff through the legal and investigatory processes that follow an adverse event, and why we must do all we can to maximise the opportunity to learn when things go wrong in healthcare.
  16. Content Article
    Patient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
  17. Content Article
    Coroners are independent judicial officers who investigate deaths reported to them. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest.
  18. Content Article
    Avoidable unsafe care kills and harms thousands of people in the UK each year. When a person dies as a result of a preventable error it is vital that we learn from these tragic events and take action to ensure that this does not reoccur. Coroners' Prevention of Future Deaths (PFD reports) are a crucial resource for this and should be used to make healthcare safer. Are we utilising these to their full extent to improve our safety practice and to achieve their aim, to prevent future deaths?
  19. Content Article
    This coroner's case, by coroner Emma Serrano, describes the events that led up to Maureen Brown's death at University Hospital of Derby and Burton NHS Trust. Maureen had an inpatient fall and died from her injuries. Could this death been prevented? How can we ensure the voice of the carer/family is heard, documented and acted upon in clinical practice?
  20. Content Article
    The purpose of these three films is to share insights about inquests and support all staff working in the NHS who are called to give evidence, so that they can prepare well following the death of a patient in their care.  They are intended to be used as a stand-alone product by those called to be a witness as well as integrated as a part of full inquest training package.
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