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News Article
Whooping cough: Cases up again as five infant deaths reported
Patient-Safety-Learning posted a news article in News
Five babies have died from whooping cough as cases continue to rise in England, health officials have announced. The UK Health Security Agency (UKHSA) reported 1,319 cases in England in March, after just over 900 in February, making the 2024 total nearly 2,800. It fears it could be a bumper year for the bacterial infection. The last peak year, 2016, saw 5,949 cases in England. The infection can be particularly serious for babies and infants. Half of cases seen so far this year have been in the under-15s, with the highest rates in babies under three months of age. The five babies who died this year were all under three months old. Known as pertussis or "100-day cough", the infection is a cyclical disease with peaks seen every three to five years. UKHSA has said a steady decline in uptake of the vaccine in pregnant women and children and the very low numbers seen during the pandemic, as happened with other infections because of restrictions and public behaviour, were both factors. The agency said a peak year was therefore overdue and urged families to come forward to get vaccinated if they had not already. Read full story Source: BBC News, 9 May 2024 -
News ArticleAn inquest into the death of a baby boy who died two weeks after birth in a Sussex hospital has found there were missed opportunities in the care of his mother. Orlando Davis was born by emergency caesarian section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on 10 September 2021 following a normal and low risk pregnancy. He was born with no heartbeat and his parents were told he had suffered an irreversible brain injury after being starved of oxygen - after his mother Robyn Davis experienced seizures during labour, caused by a rare condition that went "completely unrecognised" by staff. Orlando died in Robyn and husband Jonny’s arms on 24 September 2021 at 14 days old due to his catastrophic brain injury. His mother had to be put in an induced coma, but has since recovered. But his parents say his death was avoidable. Today at the inquest into Orlando's death, senior coroner, Ms Penelope Schofield said a lack of understanding of hyponatremia contributed to neglect of Orlando. Mrs Davis had told the inquest: “I can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the trust for not keeping us safe. Mrs Davis continued: “The thing I cannot process is that I have lost my healthy, full-term son. I feel as if my son was taken from me in a circumstance that, in my personal and professional opinion, was completely preventable. Read full story Source: ITVX, 14 March 2024
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News ArticleA 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS). Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition. EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare. Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness. Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her. There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said. She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said. Read full story Source: The Independent, 6 September 2023
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Content Article
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Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths. -
News Article
'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 -
News Article
Inquest finds gross failings in care of woman who drank too much water
Patient-Safety-Learning posted a news article in News
An inquest jury has found there were “gross failings in care amounting to neglect” before a woman had a heart attack at a private mental health hospital due to complications from drinking excessive amounts of water. Lillian Lucas, 28, known as Lily to her family and friends, died in September 2022 after being found unresponsive in her room on Milton ward at the Cygnet hospital in Kewstoke, near Weston-super-Mare, where she had been an inpatient since June. An inquest jury at Avon coroner’s court found on Wednesday that opportunities were missed by staff to render care that would have prevented Lucas’s death, including a failure to monitor her worsening condition and inadequate response to her deterioration. On 8 September 2022 she was found unresponsive in her room after drinking excessive amounts of water and transferred to Bristol Royal Infirmary (BRI), the jury heard. She died the following day. Postmortem examinations found she died of a heart attack and the impact of psychogenic polydipsia, when due to a mental disorder a person experiences an uncontrollable urge to drink water. The jury concluded on Wednesday that there were “gross failings in her care amounting to neglect”. In the record of the inquest, the jury said the Milton ward was “understaffed at a level deemed to be unsafe”. Read full story Source: Guardian, 24 April 2024 -
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 ArticleInga Rublite died after being found unconscious under her coat in an A&E waiting room more than eight hours after arriving. Learning what happened to Rublite in the hours before her death has been gut-wrenching for her friends and family. She sat through the night at Queen’s Medical Centre (QMC) in Nottingham after arriving at 10.30pm on 19 January with severe headache, dizziness, high blood pressure and vomiting. When her name was called seven hours later, at about 5.30am, she did not respond and staff discharged her believing she had tired of waiting and gone home. But over an hour later she was discovered having a seizure after falling asleep, and then unconscious, under her coat. She was rushed to intensive care but had suffered a brain haemorrhage, and the bleeding was so severe it was inoperable. She was declared dead two days later on 22 January, when her life support was switched off. Inga's twin sister said, “In all those years, the one time she went to the hospital to ask for help, no one was looking at her. I can’t describe how that feels. That you can’t get help in the place where you’re supposed to go for help.” Read full story Source: Guardian, 26 April 2024
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News ArticleA bereaved father whose vulnerable son died after managing to escape from the Priory has called for a criminal inquiry into the mental health care group after the deaths of four more patients. Richard Caseby, who lost his son Matthew, has campaigned for three years against the privately run group after an inquest found his son’s death was contributed to by neglect. The 23-year-old was able to abscond from the hospital over a fence which had previously been identified as a risk. He was hit by a train just hours later. Now the Priory, one of the UK’s largest mental health providers, faces new scrutiny as coroners are set to examine the death of 20-year-old Amina Ismail, who died while at the Cheadle Royal Hospital in Stockport. Ms Ismail died in September 2023, a year after three other young women died at the same unit - Beth Matthews, 26, Lauren Bridges, aged 20, and 30-year-old Deseree Fitzpatrick. Mr Caseby, a former newspaper editor, told The Independent: “The Priory is a fundamentally dangerous company, one that persistently refuses to learn from its mistakes and neglect. The roll call of death and disgrace at its hospitals just gets longer.” Read full story Source: Independent, 25 April 2024
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Content ArticleClive Treacey, who had a learning disability, epilepsy and complex mental health needs, died in 2017 aged 47, having spent his adult life in residential social care and inpatient settings. In 1993, he was placed by Staffordshire County Council into the David Lewis Centre in the borough of Cheshire East, where it is alleged he was sexually abused by a member of staff. Cheshire East Safeguarding Adults Board (CESAB) and Staffordshire and Stoke-on-Trent Adults Safeguarding Partnership Board (SSASPB) jointly commissioned a Discretionary Safeguarding Adults Review (D-SAR) to look at Clive's case. Authored by Professor Michael Preston-Shoot, the review relates to historical incidents of abuse and examines what is now in place to protect adults at risk since adult safeguarding became a statutory duty under the Care Act in 2014. The SAR makes 14 recommendations to the boards.
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Content ArticleMeasures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognize or respond to deterioration. The current study explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients.
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News Article
Asthma: Action needed on needless deaths, says charity
Patient Safety Learning posted a news article in News
Urgent government action is needed to stop preventable asthma deaths, a leading charity has said. More than 12,000 people in the UK have died from asthma attacks since 2014, according to Asthma and Lung UK. It said the figures meant "shockingly little" had changed since a major report a decade ago which found two thirds of asthma deaths could have been avoided with better care. People with asthma should get an annual condition review, a written action plan and inhaler technique checks. But the charity said people with asthma were being "failed", with seven out of 10 not receiving basic care, partly because healthcare workers were over-stretched. Asthma and Lung UK said 31% of asthmatics were "disengaged" with managing their condition, putting them at higher risk, according to its research. Ministers in England and Wales said they were trying to improve services. Read full story Source: BBC News, 24 April 2024 -
Content ArticleChildren being subjected to lethal medical experiments sounds like the plot of a dystopian horror film. Yet that is exactly what happened in the UK in the 1970s and 80s. New documents seen last week by the BBC reveal the extent to which children with haemophilia and other blood clotting disorders were enrolled in clinical trials, often without their parents’ consent. Most of them were infected with HIV or hepatitis C as a result of being treated with blood products that doctors knew could kill them. At one boarding school for boys with haemophilia used by the doctors conducting these trials, Treloar College in Hampshire, 75 out of the 122 pupils who attended between 1974 and 1987 have died as a result of their HIV or hepatitis C infections. The independent inquiry on the contaminated blood scandal estimated that 1,250 people contracted both HIV and hepatitis C as a result of these agents, and between 2,400 and 5,000 people hepatitis C alone. Others contracted these viruses after receiving blood transfusions following surgery or childbirth; it is thought that up to 100 people were infected with HIV this way, and 27,000 people with hepatitis C. Around 2,900 people have died so far. One gets a sense of the horrific trauma the state inflicted on people by reading the evidence those affected gave the inquiry.
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News Article
Block on data sharing contributed to death
Patient Safety Learning posted a news article in News
A failure to share medical information between IT systems contributed to the death of a man in prison custody, a coroner has concluded. In a newly published report on the death of Finlay Finlayson at HMP Lewes in 2019, the coroner highlighted “information sharing” problems and “permissions issues” between the prison IT system and that of the man’s GP surgery. Mr Finlayson died from blood clots in his lungs, having suffered from multiple long-term health conditions including cancer during his life. At the time of his death in 2019, health services at HMP Lewes were provided by Sussex Partnership Foundation Trust, though they are now provided by the Practice Plus Group. According to the Prevention of Future Deaths report issued last month, coroner Laura Bradford heard evidence that Mr Finlayson’s care was affected by “confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne”. It appears the GP practice had not enabled sharing of the data, which would have been required for it to be accessed in the prison. Read full story (paywalled) Source: HSJ, 22 April 2024 Further reading on the hub: NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? The digitalising of patient records — why patients MUST be involved -
Content Article
Digital storytelling: Learning opportunity or reputational risk?
Anonymous posted an article in Culture
In this anonymous blog, a member of NHS staff talks about their experience promoting digital storytelling to help staff members and the wider trust learn from patients’ perspectives on incidents of harm. They describe the conflicting pressures of leaders’ concerns about how these stories might affect the Trust's reputation and the need to be transparent with patients and staff.- Posted
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Content Article'Vinney' died of pulmonary thromboemboli due to deep vein thrombosis with a background of metastatic carcinoma of the base of the tongue following cardiac arrest on 25 January 2019 at HMP Lewes (Cell 216 on C-Wing), whilst on remand. He was pronounced dead at 9.16 am. The jury considered that Vinney’s care was affected by the following issues, the absence of which may have delayed or changed the circumstances of his death. There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney’s own statements. Some poor record keeping on SystmOne and confusion over when to reference the system. This affected both plans and reporting of interactions. Failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare. This was particularly relevant between 21 and 24 January 19. In particular a lack of quantifiable evidence, e.g. NEWS scores or notes of proportionate follow-ups and recorded observations between 21 and 24/1/19 which may have allowed any deterioration in Vinney’s condition to be missed. On 25/1/19, there was a grave and unacceptable failure in communications with two or three emergency radios switched off in contravention of prison rules and protocols. This was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response, which may have been longer had it not been for decisive intervention from comms. This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney’s mental health were a factor, and should have been automatic on account of his head injury.
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Content ArticleLittle is known as to whether the effects of physician sex on patients’ clinical outcomes vary by patient sex. This study examined whether the association between physician sex and hospital outcomes varied between female and male patients hospitalised with medical conditions. The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients.
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News Article
Leaked NHS figures reveal 15,000 died in care of mental health trusts in one year
Patient Safety Learning posted a news article in News
The shocking number of patients who are dying while under the care of stretched community mental health services can be revealed for the first time after a major NHS report was leaked to The Independent. More than 15,000 people are estimated to have died in a single year while being cared for by community mental health teams – as trusts scramble for staff and funding while the demand for care is at an all-time high. The figures, which relate to deaths between March 2022 and March 2023, can be revealed after a concerned insider handed the secret report to this publication. Health officials admitted the statistics had been collated for the first time last year in a bid to reduce deaths – but have not made them public. The leaked report reveals that: At least 137 women died between 2022 and 2023 while under the care of services for pregnant women at one unnamed trust. Nearly one in 10 of the patients treated by a crisis service – designed to help those with the most severe mental health conditions – died while under that care. One unnamed mental health trust recorded more than 500 deaths in that year-long period. Read full story Source: The Independent, 22 April 2024 -
News Article
Letby to seek permission for conviction appeal
Patient Safety Learning posted a news article in News
Lucy Letby is to apply for permission to appeal against her convictions for the murder and attempted murder of babies in her care. A panel of three judges at the Court of Appeal in London is due to consider the former nurse’s case later. The 34-year-old was handed 14 whole life terms last year. She was found guilty of murdering seven babies and attempting to murder a further six at the Countess of Chester Hospital between 2015 and 2016. Second stage Shortly after her trial ended in August, Letby applied for leave to appeal against her convictions. She lost the first stage of the process, in which a single judge reviewed her arguments as a paper exercise. Letby, originally of Hereford, now has the right to a second stage, which involves renewing her application before a panel of judges at a hearing at the Court of Appeal. Separately to the appeal, Letby is due to be re-tried on one charge of attempted murder, which the jury at her trial was unable to decide on. Read full story Source: BBC News, 2 April 2024 -
Content ArticleAround 1.3 million people in England have a learning disability and may need more support to stay in good health. But are they able to get access to the services they are entitled to in order to prevent illness? This Nuffield Trust report looks at a set of five key preventive healthcare services and functions to understand whether they are working as they should for people with a learning disability.
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Content ArticleDiagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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News Article
Seven more avoidable sepsis deaths spark coroner warnings
Patient Safety Learning posted a news article in News
Preventable deaths of seven people from sepsis – including four children – have prompted coroners to flag major concerns about NHS services’ management of the condition. Since the start of March, six English coroners have sent formal warnings to trusts, NHS England and the government warning of systemic failures to spot sepsis and delays in administering antibiotic treatments. It comes after an HSJ investigation in February uncovered more than 30 avoidable deaths from sepsis, and undertook analysis of internal figures revealing repeated failures by NHS trusts to provide prompt treatment. Coroner warnings since March include: Two notices were sent this week by Nottingham assistant coroner Elizabeth Didcock to Sherwood Forest Hospitals Foundation Trust, raising concerns over its ability to provide safe paediatric care following the deaths of 10-week-old Tommy Gillman and five-year-old Meha Carneiro from sepsis; A warning from earlier in April criticising University Hospitals Birmingham FT for its failure to treat 56-year-old Tracey Farndon’s sepsis and low blood pressure. Read full story (paywalled) Source: HSJ, 17 April 2024 -
Content ArticleThis French cohort study in JAMA Internal Medicine aimed to find out whether spending a night in the emergency department (ED) associated with increased in-hospital mortality and morbidity among older patients. The results showed that older patients who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight. This finding was particularly notable among patients with limited autonomy.
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News Article
Concerns at Nottinghamshire hospital after baby's sepsis death
Patient Safety Learning posted a news article in News
The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024 -
Content ArticleTommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.
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