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Found 1,495 results
  1. Content Article
    At the time of her death, Heather Findlay, aged 28 years, was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. At inquest, the jury came to a conclusion of death by suicide and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity.
  2. News Article
    Britain’s health regulator has partly suspended the manufacturing licence of Sciensus, a private company paid millions by the NHS to provide vital medicines, after the death of a cancer patient who was given the wrong dose of chemotherapy. The Medicines and Healthcare products Regulatory Agency (MHRA) said it had taken “immediate” action under regulation 28 of the Human Medicines Regulations 2012 law “where it appears to the MHRA that in the interests of safety the licence should be suspended”. The MHRA found “significant deficiencies” in standards at Sciensus during an investigation triggered by the death of one patient and the hospitalisation of three others. All four patients were administered “incorrect” doses of an unlicensed version of cabazitaxel, a licensed chemotherapy used to treat prostate cancer, according to people familiar with the matter. Read full story Source: The Guardian, 25 July 2023
  3. News Article
    The deaths of dozens of people who took their own lives while patients of an NHS trust will be reviewed after concerns were raised. Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) will review all 63 suicides since 2017. It comes after the trust was accused of adding to the records of Charles Ndhlovu, 33, the day after he took his own life to "correct their mistakes". Mr Ndhlovu, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care for two months when he died in Ely in 2017. Last month, his mother Angelina Pattison, from Newmarket, Suffolk, told the BBC his care plan "was done when he died - when they were running around to correct their mistakes, which they have done". Read full story Source: BBC News, 25 July 2023
  4. News Article
    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
  5. News Article
    America is facing an intensified push to pass stalled federal legislation to address the US’s alarming maternal mortality rates and glaring racial disparities which have led to especially soaring death rates among Black women giving birth. Maternal mortality rates in the US far outpace rates in other industrialised nations, with rates more than double those of countries such as France, Canada, the UK, Australia, Germany. Moms in the US are dying at the highest rates in the developed world. Overall maternal mortality rates in the US spiked during the pandemic. Maternal deaths in the US rose 40% from 861 in 2020 to 1,205 in 2021, a rate of 32.9 deaths per 100,000 live births. For Black women, these maternal mortality rates were significantly higher, at 69.9 deaths per 100,000 live births in 2021. These racial disparities in maternal health outcomes have persisted and worsened for years as the number of women who die giving birth in the US has more than doubled in the last two decades. The CDC noted in a review of maternal mortalities in the US from 2017 to 2019, that 84% of the recorded maternal deaths were preventable. Read full story Source: The Guardian, 23 July 2023
  6. News Article
    Women who lose babies during pregnancy will be able to get a certificate as an official recognition of their loss as well as better collection and storage of remains under new government plans. The government will make sure the certificate is available to anyone who requests one after experiencing any loss pre-24 weeks’ gestation. The NHS will develop and deliver a sensitive receptacle to collect baby loss remains when a person miscarries. A&Es will also have to ensure that cold storage facilities are available to receive and store remains or pregnancy tissue 24/7 so that women don’t have to resort to storing them in their home refrigerators. The new recommendations are part of the government’s response to the independent Pregnancy Loss Review. Read full story Source: The Independent, 23 July 2023
  7. Content Article
    A vision for improving the care and support available to families when baby loss occurs before 24 weeks' gestation.
  8. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services.
  9. News Article
    The bodies of people who died with Covid were treated like "toxic waste" and families were left in shock, a bereaved woman has told the inquiry. Anna-Louise Marsh-Rees said her father Ian died "gasping for breath" after catching the virus while in hospital. Ms Marsh-Rees, who leads Covid-19 Bereaved Families for Justice Cymru, said he was "zipped away", and his belongings put in a Tesco carrier bag. Ian Marsh-Rees died after catching the virus while in hospital, aged 85. His daughter said finding information regarding his care in hospital and how he became infected was "almost like an Agatha Christie mystery". She said no GP ever suggested he might have Covid, although she now knows his discharge notes said he had been exposed to Covid. "It wasn't until we saw his notes some months later that we saw the DNA CPR (do not attempt CPR) placed on him, and this was without consultation with us," she said. "It kind of haunts us all that… people used to say 'well they're in the right place' when they go to hospital. I'm not sure they would say that any more," Ms Marsh-Rees said. She now wants to change the way deaths are handled by health boards. She said it was important to prepare families before and support them after the death of a loved one, from palliative care to dignity in death. Read full story Source: BBC News, 18 July 2023
  10. News Article
    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
  11. Content Article
    Food allergy affects around 7-8% of children worldwide, or about two children in an average-sized classroom. As children spend at least 20% of their waking hours in school, it is not surprising that data show that 18% of food allergy reactions and 25% of first-time anaphylactic reactions occur at school. This report by the Benedict Blythe Foundations looks at the prevalence and seriousness of allergies in school-aged children, and the devastating consequences when things go wrong at school.
  12. News Article
    More families have been told by a health board that their relatives' deaths may have been linked to treatment by vascular services. Betsi Cadwaladr University Health Board (BCUHB) has written to families who were part of a review after concerns were raised last year. Four cases had already been reported to a coroner and the health board says it has been "very open" with relatives of other patients. The service has recently been described by inspectors as making "satisfactory progress", but the health board admit it is still on a "long journey". A report by the Royal College of Surgeons England (RCSE) in January 2022 found risks to patient safety due, in part, to poor record keeping. It recommended to the health board that it investigate fully what happened to the 47 patients its report focused on. Read full story Source: BBC News, 13 July 2023
  13. News Article
    Black women in the Americas bear a heavier burden of maternal mortality than their peers, but according to a report released Wednesday by the United Nations, the gap between who lives and who dies is especially wide in the world’s richest nation — the United States. Of the region’s 35 countries, only four publish comparable maternal mortality data by race, according to the report, which analyzed the maternal health of women and girls of African descent in the Americas: Brazil, Colombia, Suriname and the United States. And while the United States had the lowest overall maternal mortality rate among those four nations, the report said Black women and girls were three times more likely than their U.S. peers to die while giving birth or in the six weeks afterward. “The risk factor is racism,” said Joia Crear-Perry, an OB/GYN and founder of the National Birth Equity Collaborative, a nonprofit group dedicated to eliminating racial inequities in birth outcomes and one of the report’s co-sponsors. “This report drives this home over and over. When your pain is ignored, when your blood pressure is ignored, you die, and that happens across the Americas.” Read full story (paywalled) Source: The Washington Post, 12 July 2023
  14. Content Article
    NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
  15. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email kate@hc-uk.org.uk hub members receive 20% off. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
  16. News Article
    A 30-year-old actress whose symptoms were dismissed as anxiety died of a blood clot. Emily Chesterton believed she had seen a GP, but had in fact been seen twice by a physician associate (PA), a newer type of medical role that involves significantly less training. Her parents, Brendan and Marion Chesterton, both 64 and retired teachers, said they have serious concerns about plans for thousands more PAs to be employed to combat staff shortages as part of the NHS Long Term Workforce Plan. Chesterton’s calf pain and shortness of breath should have suggested a pulmonary embolism and meant she was sent to A&E. A coroner concluded this would probably have saved her life. Instead she was told to take anxiety pills. She collapsed that evening. She was taken to hospital but her heart stopped and she could not be revived. Read full story (paywalled) Source: The Times, 10 July 2023
  17. News Article
    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
  18. News Article
    A review into failings in maternity care in hospitals in Nottingham is set to become the largest in the UK, the BBC understands. Donna Ockenden, chair of the inquiry, is expected to announce that 1,700 families' cases will be examined. She was in charge of the probe into services in Shropshire, which found at least 201 babies and mothers might have survived had they received better care. The review comes after dozens of baby deaths and injuries in Nottingham and focuses on the maternity units at the Queen's Medical Centre and City Hospital. So far, 1,266 families have contacted the review team themselves directly and to date, 674 of these have given consent to join it. But Ms Ockenden has called for a "radical review" to ensure "women from all communities" were being contacted by the trust and "felt confident" to come forward. Read full story Source: BBC News, 10 July 2023
  19. Content Article
    Gloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
  20. Content Article
    This policy explains how the Structured Judgement Review (SJR) process is implemented within Maidstone and Tunbridge Wells NHS Trust. The policy advises staff on how to undertake a mortality case record review, which documentation to use, in which circumstances an SJR is required and how the new process relates to previous systems and processes. The policy also explains how the process links to revised mortality reporting, escalation of concerns and dissemination of learning. It covers all inpatients and Emergency Department patients who die whilst in the Trust’s care, and patients who die within 30 days of discharge.
  21. News Article
    A growing number of disadvantaged and vulnerable women living in one of the poorest parts of England are dying prematurely because public services are not meeting their needs, according to a report. Research published on Monday calculates that in 2021, a woman in the north-east of England was 1.7 times more likely to die early as a result of suicide, addiction or domestic murder than women living in England and Wales as a whole. Laura McIntyre, the head of women and children’s services at Changing Lives, described the report as shocking. “But I’m more saddened,” she said. “To not reach your 40th birthday is just not right.” The report says the reasons for early and avoidable deaths are complicated, involving a patchwork of unaddressed issues including domestic abuse, debt, poverty, mental and physical ill-health, alcohol and substance misuse, and housing problems. But the conclusions are striking. “Put plainly, women living in the north-east are more likely to live shorter lives, to spend a larger proportion of time living in poor health and to die prematurely from preventable diseases,” the report states. Read full story Source: The Guardian, 10 July 2023
  22. News Article
    A cancer patient has died and three others have been hospitalised after they were administered unlicensed versions of chemotherapy by Sciensus, a private company paid millions by the NHS to provide essential medication. Three health regulators have launched inquiries into the incident, according to people familiar with the matter. It was caused by an issue at the firm’s medicines manufacturing unit. In a statement, Sciensus confirmed an “isolated incident” had “affected four patients” and that it was “deeply saddened” that one of them had died. Sciensus offered its “sincere condolences” to the family and friends of the patient who died, and is conducting a thorough investigation, it added. The four patients received unlicensed versions of cabazitaxel, a licensed chemotherapy used to treat prostate cancer. The versions administered to the patients differed from the licensed product and therefore were considered unlicensed medicines. Sciensus is required to comply with official standards to ensure the quality of the products it produces and the protection of public health. Breaches of these standards can result in the MHRA suspending or removing a company’s licence. “Patient safety is our highest priority,” said Dr Alison Cave, the MHRA’s chief safety officer. “We are urgently investigating this issue and we will take any necessary regulatory measures to ensure patients are protected." Read full story Source: The Guardian, 7 July 2023
  23. News Article
    Maternal mortality rates have doubled in the US over the last two decades - with deaths highest among black mothers, a new study suggests. American Indian and Alaska Native women saw the greatest increase, the study in Journal of the American Medical Association (JAMA) said. Southern states had the highest maternal death rates across all race and ethnicity groups, the study found. In 1999, there were an estimated 12.7 deaths per 100,000 live births and in 2019 that figure rose to 32.2 deaths per 100,000 live births in 2019, according to the research, which did not study data from the pandemic years. Unlike other studies, this one examined disparities within states instead of measuring rates at the national level, and it monitored five racial and ethnic groups. Dr Allison Bryant, one of the study's authors, said the findings were a call to action "to understand that some of it is about health care and access to health care, but a lot of it is about structural racism". She said some current policies and procedures "may keep people from being healthy". Read full story Source: BBC News, 4 July 2023
  24. Content Article
    Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. The objective of this study was to quantify trends in MMRs (maternal deaths per 100 000 live births) by state for five mutually exclusive racial and ethnic groups using a bayesian extension of the generalised linear model network. The study found that while maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.
  25. News Article
    The government has rejected calls to set a target and strategy to end ‘appalling’ disparities in maternal deaths. In response to a Commons women and equalities committee report, published on Friday, ministers said a “concrete target does not necessarily focus resource and attention through the best mechanisms”. The response added: “We do not believe a target and strategy is the best approach towards progress.” The government said disparities will be monitored through local maternity and neonatal systems, which are partnerships comprising commissioners, providers and local authorities. A recommendation to increase the annual budget for maternity services to up to £350m per year, backed by the now chancellor Jeremy Hunt, and maternity investigator Donna Ockenden, was also rejected. Read full story Source: HSJ, 3 July 2023
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