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Found 1,491 results
  1. News Article
    Trusts have been told to check the safety of their helipads after an accident in a hospital car park left a pensioner dead. Jean Langan, 87, was blown over by the “downwash” of air from a helicopter at Derriford Hospital last year. She was walking through a car park at the hospital after an appointment when she fell and hit her head as an HM Coastguard helicopter landed on the hospital’s helipad. Another elderly woman broke her pelvis. Now the Health and Safety Executive has written to trust chief executives reminding them of their duty to manage health and safety risks around helipads. These risks include downwash from helicopters, the moving parts of helicopters, and the design and location of helipads. Read full story (paywalled) Source: HSJ, 2 August 2023
  2. News Article
    Serious systemic failings contributed to the death of a newborn baby in a cell at Europe’s largest women’s prison, a coroner has concluded. Rianna Cleary, who was 18 at the time, gave birth to her daughter Aisha alone in her prison cell at HMP Bronzefield, in Surrey, on the night of 26 September 2019. The care-leaver was on remand awaiting sentence after pleading guilty to a robbery charge. The inquest into the baby’s death heard that Cleary’s calls for help when she was in labour were ignored, she was left alone in her cell for 12 hours and bit through the umbilical cord to cut it. In a devastating witness statement read to the court, Cleary described going into labour alone as “the worst and most terrifying and degrading experience of my life”. She said: “I didn’t know when I was due to give birth. I was in really serious pain. I went to the buzzer and asked for a nurse or an ambulance twice.” Cleary passed out and when she woke up she had given birth. The senior coroner for Surrey, Richard Travers, said Aisha “arrived into the world in the most harrowing of circumstances”. He concluded it was “unascertained” whether she was born alive and died shortly after or was stillborn. Read full story Source: The Guardian, 28 July 2023
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. News Article
    A Colorado surgeon has been convicted of manslaughter in the death of a teenage patient who went into a coma during breast augmentation surgery and died a year later. Emmalyn Nguyen, who was 18 when she underwent the procedure 1 August 2019, at Colorado Aesthetic and Plastic Surgery in Greenfield Village, near Denver, fell into a coma and went into cardiac arrest after she received anaesthesia, officials said. She died at a nursing home in October 2020. Dr. Geoffrey Kim, 54, a plastic surgeon, was found guilty of attempted reckless manslaughter and obstruction of telephone service. At Kim’s trial, a nurse anesthetist testified that he advised Kim that the patient needed immediate medical attention in a hospital setting and that 911 should be called, prosecutors said. An investigation determined Kim failed to call for help for five hours after the patient went into cardiac arrest, prosecutors said. The obstruction charge was linked to testimony that multiple medical professionals, including two nurses, requested permission to call 911 to transfer care for Nguyen, but Kim, the owner of the surgery centre, denied the request, prosecutors said. Read full story Source: ABC News, 15 June 2023
  19. News Article
    A paramedic was hallucinating after a traumatic call-out when he crashed into a car, an inquest heard. Jason Allen, 49, and Andrew Ralph, 61, were killed after their car was hit by Kevin Lilwall's ambulance on the A49 in Pengethley, Herefordshire. An inquest heard Mr Lilwall was having flashbacks to the previous day when he had been in the area responding to the sudden death of a baby. The paramedic, who had worked for West Midlands Ambulance Service (WMAS) for 28 years, was driving the ambulance when it crossed the white line into the car. The ambulance dashcam showed it heading directly towards Mr Allen’s car for six seconds before the collision. The families of Mr Allen and Mr Ralph said they had been through hell in the past four years, adding they had never had an apology from Mr Lilwall and only one from WMAS after the inquest. The hearing in Hereford was told Mr Lilwall had spent more than 25 hours on duty in the previous 36 hours, with just a 10-hour break between shifts. Medical experts agreed that the hallucination could have been caused by post traumatic stress disorder. Jason Wiles from WMAS admitted it had been a "missed opportunity" regarding the apology and said it had changed its policy to ensure staff had a break of at least 11 hours between shifts following the crash. Read full story Source: BBC News, 28 June 2023
  20. News Article
    An inquiry investigating deaths of mental health patients in Essex has been given extra powers, in a victory for campaigners. Health Secretary Steve Barclay told Parliament that the probe would be placed on a statutory footing. It means the inquiry can force witnesses to give evidence, including former staff who have previously worked for services within the county. Mr Barclay said he was committed to getting answers for the families. He told the Commons: "I hope today's announcement will come as some comfort to the brave families who have done so much to raise awareness." The Secretary of State added that under the new powers anyone refusing to give evidence could be fined. Melanie Leahy, whose son Matthew died while an inpatient at the Linden Centre in Chelmsford in 2012, is among those who have long campaigned for the inquiry to be upgraded. "Today's announcement marks the start of the next chapter in our mission to find out how our loved ones could be so badly failed by those who were meant to care for them," said Ms Leahy. "I welcome today's long overdue government announcement and I look forward to working with the inquiry team as they look to shape their terms of reference." Read full story Source: BBC News, 28 June 2023
  21. News Article
    Today it was announced by the Secretary of State for Health and Social Care that the future Health Services Safety Investigations Body (HSSIB) will undertake a series of investigations focused on mental health inpatient settings. The investigations will commence when HSSIB is formally established on 1 October 2023. The HSSIB will conduct investigations around: How providers learn from deaths in their care and use that learning to improve their services, including post-discharge. How young people with mental health needs are cared for in inpatient services and how their care could be improved. How out-of-area placements are handled. How to develop a safe, therapeutic staffing model for all mental health inpatient services. Rosie Benneyworth, Chief Investigator at HSIB, says: “We welcome the announcement by the Secretary of State and see this as a significant opportunity to use our expertise, and the wider remit that HSSIB will have, to improve safety for those being cared for in mental health inpatient settings across England. The evidence we have gathered through HSIB investigations has helped shed light on some of the wider challenges faced by patients with mental health needs, and the expertise we will carry through from HSIB to HSSIB will help us to further understand these concerns in inpatient settings, and contribute to a system level understanding of the challenges in providing care in mental health hospitals. “HSSIB will be able to look at inpatient mental health care in both the NHS and the independent sector and any evidence we gather during the investigations is given full protection from disclosure. It is crucial that those impacted by poor care and those working on the frontlines of the inpatient settings can share their experiences, reassured that HSSIB will use this information to improve care and not apportion blame or liability. “At HSIB we will begin conversations with our national partners across the system, as well as talking to staff, patients and families. This will ensure that when investigations are launched in October, we have identified and will address the most serious risks to mental health inpatients within these areas and will identify recommendations and other safety learning that will lead to changes in the safety culture and how safety is managed within mental health services.” Read full story Source: HSIB, 28 June 2023
  22. News Article
    Ex-health secretary Matt Hancock has criticised the UK's pandemic planning before Covid hit, saying it was "completely wrong". He told the Covid Inquiry that planning was focused on the provision of body bags and how to bury the dead, rather than stopping the virus taking hold. He said he was "profoundly sorry" for each death. After giving evidence he approached some of the bereaved families, but they turned their backs on him as he left. The former health secretary, who answered questions from the inquiry on Tuesday, said he understood his apology might be difficult for families to accept, even though it was "honest and heartfelt". Under questioning from Hugo Keith KC, lead counsel to the Covid Inquiry, Mr Hancock stressed that the "attitude, the doctrine of the UK was to plan for the consequences of a disaster". Read full story Source: BBC News, 27 June 2023
  23. News Article
    An independent review has raised concerns about a mental health trust’s reporting systems and has highlighted a significant number of patient deaths shortly after leaving the trust’s care, including almost 300 who died on the same day they were discharged. However, the review into how Norfolk and Suffolk Foundation Trust collects, processes and reports mortality data made no conclusions on the number of avoidable deaths – the issue which had originally prompted the probe. Local NHS leaders argued the review’s purpose was focused on auditing the trust’s processes, and this had been delivered. But a local MP, Clive Lewis, accused it of “explicitly dodg[ing] the big questions”. The report, which looked at data from between April 2019 and October 2022, has however raised concerns about the number of patients dying soon after being discharged. Read full story (paywalled) Source: HSJ, 28 June 2023
  24. News Article
    Relatives of a teenage rape survivor who died after failures by mental health services are joining other families to demand a new body to enforce coroners’ recommendations to prevent future deaths. Campaigners claim the failure to act on hundreds of coroners’ recommendations every year, and to learn from the findings of often expensive inquiries into disasters, means the same mistakes are being repeated. Gaia Pope, 19, was diagnosed with post-traumatic stress disorder after revealing that she had been drugged and raped when she was 16. She was found dead in undergrowth on a cliff 11 days after disappearing in Swanage, Dorset, in 2017. After one of the longest inquests in legal history, the coroner, Rachael Griffin, made multiple reports last year to authorities including the NHS and police to prevent future deaths, but Pope’s family says most have not been acted upon. The Inquest campaign, which works with families bereaved by state-related deaths, is calling for a “national oversight mechanism” to collate recommendations and responses in a new national database, analyse responses from public bodies, follow up on progress and share common findings. Read full story (paywalled) Source: The Times, 27 June 2023
  25. News Article
    What would the NHS see if it looked in a mirror, asks Siva Anandaciva, author of the King’s Fund’s study comparing the health service with those of 18 other rich countries, in the introduction to his timely and sobering 118-page report. The answer, he says, is “a service that has seen better days”. Britons die sooner from cancer and heart disease than people in many other rich countries, partly because of the NHS’s lack of beds, staff and scanners, a study has found. The UK “underperforms significantly” on tackling its biggest killer diseases, in part because the NHS has been weakened by years of underinvestment, according to the report from the King’s Fund health thinktank. It “performs poorly” as judged by the number of avoidable deaths resulting from disease and injury and also by fatalities that could have been prevented had patients received better or quicker treatment. The comparative study of 19 well-off nations concluded that Britain achieves only “below average” health outcomes because it spends a “below average” amount for every person on healthcare. Read full story Source: The Guardian, 26 June 2023
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