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Found 1,489 results
  1. News Article
    Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake. The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyser, which stopped the patient’s breathing and left her brain-dead before the error was discovered. Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became “complacent” in her job and “distracted” by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone. “I know the reason this patient is no longer here is because of me,” Vaught said, starting to cry. “There won’t ever be a day that goes by that I don’t think about what I did.” If Vaught’s story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught’s case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on the 27 December 2017. Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught’s loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day. Read full story Source: Kaiser Health News, 22 March 2022
  2. News Article
    The number of people who have died from Covid in Britain during the pandemic is impossible to determine because of the inconsistent definitions of what is meant by a coronavirus death, researchers have concluded. Experts from Oxford University discovered that public health and statistics organisations across the UK are operating under 14 different definitions to classify a death from Covid. Freedom of Information (FOI) requests show that many people who died in the first wave never tested positive for the virus, particularly older people who died in care homes. Instead, their deaths were registered as Covid simply based on a statement of the care home provider, and because coronavirus was rife at the time. The authors also point out that it is unlikely that a Covid infection on its own could cause death in the absence of contributing factors, such as other illness, or the infection leading to a more deadly condition such as pneumonia. The report also found that in some trusts, up to 95% of Covid deaths were in people with Do Not Resuscitate (DNR) orders. The team said the confusion meant they were unable to separate deaths caused by Covid from those triggered by the pandemic response, and called for a proportion of deaths to be verified by post-mortem in future pandemics to determine the true reason. Read full story (paywalled) Source: The Telegraph, 19 March 2022
  3. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022
  4. News Article
    A paediatrician who was at the centre of one of Northern Ireland's longest running public inquiries will appear before a professional misconduct panel. Dr Heather Steen is accused of several failings following the death of Claire Roberts at the Royal Belfast Hospital for Sick Children in October 1996. The nine-year-old's death was examined by the hyponatraemia inquiry, which lasted 14 years. It examined the role of several doctors. Among his findings, the inquiry's chairman Mr Justice O'Hara said there had been a "cover-up" to "avoid scrutiny." Monday's tribunal will inquire into allegations that, between 23 October 1996 and 4 May 2006, Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of the child's death. Also that the doctor provided inappropriate, incomplete and inaccurate information to the child's parents and GP regarding the treatment, diagnosis, clinical management and cause of her death. The tribunal website adds: "It is also alleged that Dr Steen inappropriately recommended a brain-only post-mortem for Patient A (Claire Roberts) when a full post-mortem was necessary. "In addition, it is alleged that Dr Steen failed to refer Patient A's death to the coroner, inappropriately completed the medical certificate of cause of death and inaccurately completed the autopsy request form for Patient A. "Furthermore, it is alleged that during a review of Patient A's notes, Dr Steen failed to consult with the necessary colleagues and medical teams and provided a statement and gave evidence to the coroner's inquest into Patient A's death which omitted key information." Read full story Source: BBC News, 21 March 2022
  5. News Article
    The carer who admitted the manslaughter of Adelaide woman Ann Marie Smith, who had cerebral palsy, has been jailed for at least five years and three months for her criminal neglect. Sentencing Rosa Maria Maione in the Supreme Court, Justice Anne Bampton said the 70-year-old was grossly negligent, with her care for Smith falling well short of the standard expected. “You did not mobilise her from the chair in which she was found. You did not toilet her properly and you did not clean her properly,” she told Maione on Friday. “You did not feed her a nutritional diet or monitor her intake. You knew you were not capable of properly supporting her and you did not seek assistance in providing for Ms Smith’s needs." “Despite the deterioration in Ms Smith’s health, you did not seek assistance from your supervisor or medical professionals until it was too late.” Justice Bampton said Maione had absolutely no insight into Smith’s physical condition leading up to her death. “Your incompetence, lack of training, lack of assertiveness and lack of supervision produced an environment where you failed to provide appropriate care,” she said. “Every person living with a disability, every person who requires support, every parent, carer and support worker of persons living with a disability, I have no doubt shudders with fear when they hear of the utter lack of care and human dignity afforded to Ms Smith in those last months of her life.” Read full story Source: The Guardian, 18 March 2022
  6. News Article
    Covid-19 is on the retreat across the American continents but it is too early for the region to let its guard down, warned the Pan American Health Organisation, the World Health Organization’s regional office for the Americas, on 9 March. Reported cases of Covid-19 fell by 26% in the past week and deaths by nearly 19%, as the omicron wave of infections tailed off. But ongoing transmission and future variants could expose the region’s public health priorities once more, said PAHO’s director, Carissa Etienne. A total of 2.6 million people have died from Covid-19 in the Americas, the highest number of any region of the world and almost half of the global total, despite being home to only 13% of its population. “This is a tragedy of enormous proportions, and its effects will be felt for years to come,” said Etienne on the second anniversary of the pandemic. Patchy vaccination coverage has left countries vulnerable to current and future variants of SARS-CoV-2. Around 248 million people in Latin America and the Caribbean are yet to receive a single dose of a covid vaccine, with vaccination rates particularly low in hard-to-reach rural areas. In the first two months of 2022 the Americas accounted for 63% of the world’s new cases. Despite a general fall in incidence across the region, new cases rose by 2.2% in the Caribbean, while Bolivia and Puerto Rico reported an increase in deaths in the past week. Michael Touchton, head of the University of Miami’s Covid-19 policy observatory for Latin America, said, “Latin America is perhaps the most vulnerable region in the world to the emergence of a new variant. Vaccine delays have a greater impact in Latin America due to concentrated urban populations, chronic disease burden, and low capacity health systems. Taken together, Latin America is likelier to fare worse than other similarly low and middle income regions.” Read full story Source: BMJ, 14 March 2022
  7. News Article
    The parents of a baby boy who lived for just 27 minutes have told an inquest they were "completely dismissed" throughout labour. Archie Batten died on 1 September 2019 at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, Kent. His inquest began on Monday at Maidstone Coroner's Court. The East Kent Hospitals University NHS Foundation Trust has already admitted liability and apologised for Archie's death. The coroner heard Archie's mother Rachel Higgs was frustrated at being turned away from the maternity unit in the morning, when she had gone to complain of vomiting and extreme pain. She was told she was not far enough into labour to be admitted. She returned home to Broadstairs with her partner Andrew Batten, but continued to feel unwell so phoned the hospital. She was told the unit was now closed. Instead, two community midwives were sent to their home, where they attempted to deliver the baby but could not find a heartbeat. Andrew Batten told the inquest the midwives looked "terrified," and that there was "an air of panic", with the midwives whispering in the hallway instead of telling him and Ms Higgs what was happening. Under examination from the family's barrister Richard Baker, Victoria Jackson, the midwife who had originally seen Ms Higgs, admitted the high number of patients she was having to deal with had affected her ability to spend time with her. Read full story Source: BBC News, 14 March 2022
  8. News Article
    A midwife found guilty of misconduct over the death of a baby six years ago is to be struck off. Claire Roberts was investigated by the Nursing and Midwifery Council (NMC) for failures in the care she gave to Pippa Griffiths - who died a day after being born at home in Myddle, Shropshire. An independent disciplinary panel described the midwife as "a danger to patients and colleagues". Ms Roberts and fellow midwife Joanna Young failed to realise the "urgency" of medical attention needed, following the birth, the panel said. They had failed to carry out a triage assessment, after Pippa's mother called staff for help because she was worried about her daughter's condition. The panel concluded Ms Roberts's fitness to practise was impaired. Inaccurate record-keeping by Ms Roberts represented "serious dishonesty", panel chair David Evans said, adding she had carried it out "in order to protect herself from disciplinary action". Her failures had represented a "significant departure from standards expected by a registered midwife," he added. Her colleague Ms Young, whose case was also heard by the panel, faced strong criticism on Wednesday, but was told she would face no sanction after the hearing concluded she had shown remorse and undergone extra training since 2016. Kayleigh Griffiths said she and her husband welcomed the findings and sanctions. "We're really relieved that one of the midwives has been struck off and actually we're also relieved to find that the other midwife has learnt and feels significant remorse for the event that took place," she said. "We realise people do make mistakes and I think how you deal with those mistakes is really important. "All we do ask is that learning was made from those and I think in one of the instances it did occur and in the other it didn't - so I think the right outcome has been found." Read full story Source: BBC News, 10 March 2022
  9. News Article
    The draft terms of reference for the UK public inquiry into the government's handling of the Covid-19 pandemic have been published. The inquiry, due to start in the spring, will play a key role in "learning lessons" from the pandemic and for the future, it said. The terms of reference were published after a consultation with inquiry chairwoman and former High Court judge Baroness Hallett, and with ministers in the devolved nations. The Scottish government has already published the terms of reference for its own Covid-19 inquiry, to be led by Judge Lady Poole. The UK-wide inquiry proposes examining a broad range of issues including: the UK's preparedness for the pandemic the use of lockdowns and other 'non-pharmaceutical' interventions such as social distancing and the use of face coverings the management of the pandemic in hospitals and care homes the procurement and provision of equipment like personal protective equipment and ventilators support for businesses and jobs, including the furlough scheme, as well as benefits and sick pay. The inquiry aims to produce "a factual, narrative account" covering decision-making at all levels of government and the response of the health and care sector as well as identifying the "lessons to be learned". Becky Kummer, spokesperson for Covid-19 Bereaved Families for Justice, said the publication was a "huge step forward" and the organisation looked forward to contributing to the consultation on the terms. Chris Hopson, chief executive of NHS Providers, which represents hospital trusts, said there was much the NHS did well during the pandemic but: "It is right the inquiry looks at areas where there were major challenges - such as infection prevention and control, access to PPE, testing, and robust epidemiological modelling." Read full story Source: BBC News, 11 March 2022
  10. News Article
    An 86-year-old man died after lying in the road waiting more than four hours for an ambulance, his family have said. George Ian Stevenson was hit by a car near his home in Johnstown, Wrexham county, last Wednesday. His family said the first 999 call was made at 19:31 GMT, and the ambulance did not arrive until 23:37 GMT. The Welsh Ambulance Service is looking into the incident, but said that at the time of the call, all its vehicles were already committed to other patients. Two off-duty paramedics stopped to help, but were reluctant to move him in case they caused further injury. Mr Stevenson's granddaughter, Ellie Williams said on the night of the accident it was raining, freezing and foggy. She said: "Left there for four hours, begging for help, waiting for help. And that makes us so sad. "A hard-working man who has paid his taxes all his life and paid into the system has been let down when he's needed them the most, and I just can't quite comprehend what has happened to him." Read full story Source: BBC News, 8 March 2022
  11. News Article
    The publication of a report into failures of maternity care at an NHS trust has been delayed again. Senior midwife Donna Ockenden has been investigating hundreds of cases in which mothers and babies may have been harmed at Shrewsbury and Telford Hospital NHS Trust (SaTh). Her report had been due to be published on 22 March after being postponed from December. In a letter to families, Ms Ockenden said that date "can no longer happen". She added it was down to "parliamentary processes" which have to happen before the final report can be published. A written statement to Parliament on Tuesday by patient safety minister Maria Caulfield said the NHS had been working to get indemnity cover. She said it would be to cover any potential legal action following the publication of the report and had been agreed in principle by the Treasury. Ms Ockenden's team has been examining 1,862 cases and it is thought to be the largest ever review of maternity care in the NHS. Her interim report published in December 2020 found some mothers were blamed for their babies' deaths. In her letter about the delay, Ms Ockenden said she and her team were "also very disappointed in the delay" and would be working to agree a new publication date. Read full story Source: BBC News, 9 March 2022
  12. News Article
    Nearly a quarter of all deaths in Great Britain were considered avoidable in 2020, according to new analysis. The Office for National Statistics said 153,008 deaths out of 672,015 – or 22.8% – were avoidable, the highest rate since 2010. Of the avoidable deaths in 2020, 68.6% were attributed to conditions considered preventable, while 31.4% were attributed to treatable conditions, the ONS said. Coronavirus has been assigned as a preventable cause in the avoidable mortality definition. Wales had the highest avoidable mortality for deaths due to Covid-19, with 36.1 deaths per 100,000 people. Scotland had the lowest rate with, 28.5 deaths per 100,000 people, and England had 34.9 deaths per 100,000 people. Avoidable mortality rates increased for alcohol-related and drug-related deaths in 2020 in all countries, the ONS analysis showed. Across England, Scotland and Wales, the increase in ASMRs for alcohol-related and drug-related conditions in 2020 was driven by alcoholic liver disease, and poisoning by, and exposure to, other and unspecified drugs, medicaments and biological substances, the ONS said. Read full story Source: The Independent, 7 March 2022
  13. News Article
    Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found. Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death. Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor. In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation. A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on. “This omission probably contributed to the death,” the jury said. It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died. Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members. Read full story Source: The Independent, 7 March 2022
  14. News Article
    A 13-year-old girl who died after contracting sepsis in an NHS hospital probably would have survived if doctors had identified the warning signs and transferred her to intensive care earlier, a coroner has ruled. Martha Mills was the first ever child to die at King’s College hospital (KCH) with a pancreatic injury of the type she sustained in a fall from her bike on an off-road family trail in Wales while on holiday last year. She was transferred to the south London hospital because it is one of three national centres for the care of children with pancreatic trauma. An inquest at St Pancras coroner’s court, north London, heard that several opportunities were missed to refer Martha to intensive care, which probably would have saved her life. In an emotional witness statement, Martha’s mother, Merope, said that after their daughter contracted an infection on 21 August last year, she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times but doctors sought to reassure them rather than escalate her care. Mills said in her statement that she explicitly raised her fears about Martha going into septic shock over the bank holiday weekend. On 29 August, Martha had high fever, low blood pressure, a racing heart and a rash, which was misdiagnosed by a junior doctor despite Mills voicing her concern that it was caused by sepsis. It was only the next day that Martha was admitted to paediatric intensive care. “I felt that my anxieties about all of Martha’s symptoms, and especially what they might mean when put together and considered in the round, weren’t given proper acknowledgement,” Mills told the court. Prof William Bernal, who produced a serious incident report on Martha’s death for KCH, said there were at least five occasions when she should have had a critical care review. He wrote that Martha’s chances of survival “would have been greatly increased” if she had been admitted to critical care earlier. The inquest heard that KCH was making changes in the wake of Martha’s death, including improving diagnostics and taking account of parents’ views. Read full story Source: The Guardian, 3 March 2022
  15. News Article
    A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found. Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable. Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day. The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late. His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care. Ombudsman Rob Behrens said: "Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial." "Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition." Read full story Source: PHSO, 3 March 2022
  16. News Article
    A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard. Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room. The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019. According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room. Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.” “Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation. Psychiatric treatment is conventionally centred on medication to manage symptoms and risk," his father said. He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given. Read full story Source: The Independent, 3 March 2022
  17. News Article
    The White House has announced plans to boost nursing home staffing and oversight, blaming some of the 200,000-plus covid deaths of nursing home residents and staff during the pandemic on inadequate conditions. Officials said the plan would set minimum staffing levels, reduce the use of shared rooms and crack down on the poorest-performing nursing homes to reduce the risk of residents contracting infectious diseases. The White House also said it planned to scrutinise the role of private equity firms, citing data that their ownership was linked with worse outcomes and higher costs. Nursing homes have been an epicenter of covid spread during the pandemic, as the virus initially tore through facilities before vaccines were available in 2020, and then continued to sicken and kill residents at an elevated rate last year. Advocates have demanded better policies to ensure the facilities are prepared for emergencies and follow practices to curb the spread of infections. Under Biden’s plan, officials at the Centers for Medicare and Medicaid Services will propose minimum staffing levels within the next year, which the White House said would improve safety by ensuring residents receive sufficient care and attention. The administration also cited a study that found increased staffing levels were linked with fewer covid cases and deaths. The nursing home industry has warned that the pandemic has exacerbated long-running staffing shortages, noting that roughly 420,000 employees in nursing homes and long-term care facilities, many of whom complained about low pay, have departed over the last two years. Read full story (paywalled) Source: The Washington Post, 28 February 2022
  18. News Article
    The police are investigating the death of a young person at a mental health hospital, The Independent can reveal. Police are investigating the death of a young girl at The Huntercombe Maidenhead mental health hospital in February. In a statement to The Independent: Thames Valley Police, said: “Thames Valley Police is conducting an investigation after the death of a girl following an incident at Huntercombe Hospital in Maidenhead on Saturday 12 February. The girl’s next of kin have been informed and our officers are supporting them. Our thoughts remain with them at this very difficult time. An investigation is ongoing to understand the circumstances around this tragic incident.” The Care Quality Commission has also said it was notified of the young girls death. The care regulator said it could not comment further. The NHS confirmed to The Independent admissions to one of the hospital’s wards have been suspended. The 60-bed hospital was rated Inadequate and placed in special measures by the CQC in February 2021 following serious concerns over care of patients. Read full story Source: The Independent, 26 February 2022
  19. News Article
    A new pregnancy screening tool cuts the risk of baby loss among women from black, Asian and ethnic minority backgrounds to the same level as white women, research suggests. The app calculates a woman's individual risk of pregnancy problems. In a study of 20,000 pregnant women, baby death rates in ethnic groups were three times lower than normal when the tool was used. Experts say the new approach can help reduce health inequalities. The screening tool is already in use at St George's Hospital in London and is being tried out at three other maternity units in England, with hopes it could be rolled out to 20 centres within two years. Researchers from Tommy's National Centre for Maternity Improvement, led by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, developed the new tool. Professor Basky Thilaganathan, who led the research team at St George's Hospital, said the new approach could "almost eliminate a large source of the healthcare inequality facing black, Asian and minority ethnic pregnant women". "We can personalise care for you and reduce the chances of having a small baby, pre-eclampsia and losing your baby," he said. The current system of a tick-box checklist to assess pregnancy risk has been around for 70 years, and is limited. The new digital tool, which uses an algorithm to calculate a woman's personal risk, can detect high-risk women more accurately and prevent complications in pregnancy, the researchers say. Both pregnant women and maternity staff can upload information on their pregnancy and how they are feeling to the app during antenatal appointments and at other times. Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said it was "unacceptable" that black, Asian and minority ethnic women faced huge inequalities on maternity outcomes. "The digital tool provides a practical way to support women with personalised care during pregnancy and make informed decisions about birth. Read full story Read Tommy's press release Source: BBC News, 28 February 2022
  20. News Article
    The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022
  21. News Article
    Pregnancy-related deaths among US mothers climbed higher in the pandemic’s first year, continuing a decades-long trend that disproportionately affects Black people, according to a new government report. Overall in 2020, there were almost 24 deaths per 100,000 births, or 861 deaths total, numbers that reflect mothers dying during pregnancy, childbirth or the year after. The rate was 20 per 100,000 in 2019. Among Black people, there were 55 maternal deaths per 100,000 births, almost triple the rate for white people. The report from the National Center for Health Statistics does not include reasons for the trend and researchers said they have not fully examined how Covid-19, which increases risks for severe illness in pregnancy, might have contributed. The coronavirus could have had an indirect effect. Many people put off medical care early in the pandemic for fear of catching the virus, and virus surges strained the healthcare system, which could have had an impact on pregnancy-related deaths, said Eugene Declercq, a professor and maternal death researcher at Boston University School of Public Health. He called the high rates “terrible news” and noted that the US has continually fared worse in maternal mortality than many other developed countries. Reasons for those disparities are not included in the data, but experts have blamed many factors including differences in rates of underlying health conditions, poor access to quality healthcare and structural racism. Read full story Source: The Guardian, 23 February 2022
  22. News Article
    Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC's Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long. Kayleigh Griffiths' baby, Pippa, died at 31 hours old. The cause of death, the couple were later told, was an infection - Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple's input wouldn't be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That's when she decided to send the email to Rhiannon Davies, whose baby, Kate, also died at the Shrewsbury and Telford Hospital NHS Trust As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner's records and death notices to see if any other families had received poor maternity care at the Shropshire trust. They collated 23 cases dating back to 2000 - including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review. One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review. It was outside any national framework that has been used to help learn lessons from incidents and doesn't appear to be a system that's used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons. One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents. The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS - the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades. Read full story Source: BBC News, 23 February 2022 Source:
  23. News Article
    A diabetic pensioner died on the roof of a hospital after staff physically ejected him despite being in a “confused” state. Stephen McManus, a long-term Type 1 diabetes patient, had earlier been rushed to Charing Cross Hospital in west London while suffering a hypoglycaemic episode. Despite colleagues having expressed concerns about his slurred speech and erratic behaviour, a junior doctor decided the 60-year-old had the mental capacity to go home. He was wheeled out of the building by security guards, despite having no phone, money and being in his slippers. His family had not been contacted to inform them he was being discharged. Some time later Mr McManus re-entered the building and managed to gain access to a construction area, somehow finding his way onto the roof. He was found dead the next morning following a police search after his family reported him missing. An inquest has begun trying to establish why Stephen was allowed to leave the hospital in the first place and how he was able to access a potentially dangerous zone. Mr McManus’s family say the case raises profound questions about the treatment of diabetic patients in the NHS. “My father was an extremely vulnerable patient and the nature of his removal from the hospital is inexplicable, Jonathan McManus, his son, told The Telegraph. “Had he been kept in hospital he would no doubt be alive today.” Read full story Source: Yahoo News, 19 February 2022
  24. News Article
    The NHS has abandoned targets that encouraged hospitals to pursue “normal births”, over fears for the safety of mothers and babies. Maternity units were told in a letter to stop using caesarean section rates to assess their performance. It comes after repeated scandals in maternity units, blamed in part on a focus on pursuing natural births at the expense of safety. The letter from Jacqueline Dunkley-Bent, NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity, instructed “all maternity services to stop using total caesarean section rates as a means of performance management”. It added: “We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases." A final report into the deaths of dozens of babies at the Shrewsbury and Telford Hospital NHS Trust will be published next month. It is expected to be highly critical. The midwife leading the inquiry, Donna Ockenden, has said women “felt pressured to have a normal birth” at the trust, adding: “There was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.” Hayley Coates, 29, lost her son Kaylan after staff at Nottingham University Hospitals NHS Trust ignored her pleas for a caesarean section in March 2018. A coroner ruled that neglect contributed to Kaylan’s death. He suffered a fractured skull when he was delivered with forceps and was starved of oxygen. Coates, a mother of three, said she welcomed the NHS England letter, adding: “I was just ignored when I asked multiple times for a caesarean section. I was told repeatedly: ‘You will have this baby naturally, you don’t want to go to theatre.’ If I had gone to theatre many hours before, my baby wouldn’t have died. They have a duty of care, and the mother’s wishes are supposed to be priority.” Read full story (paywalled) Source: The Times, 20 February 2022
  25. News Article
    A man who died from a mixed medication overdose might still be alive if the help his partner was "begging" for had been provided, a coroner said. Mental health patient Benjamin Stroud, 42, had been under the care of Essex Partnership University NHS Trust (EPUT) in the weeks before his death in March. Essex coroner Michelle Brown said in a post-inquest report that, despite "escalating psychosis", his care co-ordinator did not flag the case. Following an overdose of medication in February, his partner, a nurse, called for psychiatric intervention and despite "begging" for help, Mr Stroud's care co-ordinator did not make a referral to the multi-disciplinary team (MDT). Mr Stroud died at home on 19 March and was found surrounded by empty insulin pens and pain medication. In her prevention of future deaths report, the coroner said: "It was clear from [his partner's] account that she had been begging the care co-ordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur and, from the evidence of EPUT, it was clear that Mr Stroud's care co-ordinator did not make any referral to the MDT, despite his escalating psychosis." The coroner added that the issue of care co-ordinators failing to document their reasons for not referring cases to the MDT had been raised at other inquests. "If these practices continue there is a real risk of future deaths occurring," Ms Brown warned. Paul Scott, chief executive at the trust, said: "We will continue to view all safety-related incidents as an opportunity to learn and make sure lessons are shared across the trust." Read full story Source: BBC News, 16 February 2022
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