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Found 1,489 results
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. News Article
    The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022
  11. News Article
    Over the past couple of months, deaths in England and Wales have been higher than would be expected for a typical summer. In July and August, there were several weeks with deaths 10% to 13% above the five-year average, meaning that in England about 900 extra people a week were dying compared with the past few years. The leading causes of death are within the typical range (the five-year average): heart and lung diseases, cancers, dementia and Alzheimer’s disease. Covid-19 deaths could account for half of the excess mortality, but the other half is puzzling, as there’s no one clear reason that jumps out. It’s likely to be a mix of factors: Covid is making us sicker and more vulnerable to other diseases (research suggests it may contribute to delayed heart attacks, strokes, and dementia); an ageing population; an extremely hot summer; and an overloaded health service meaning that people are dying from lack of timely medical care. The excess mortality puzzle has been weaponised by some to argue that this is a delayed consequence of lockdown. In essence, this is to say that mandatory restrictions on mixing and stay-at-home legal orders, as well as turning the NHS into a Covid health service during the first and second waves of infection, prevented people from being diagnosed or treated for other conditions such as cancer, heart disease, or even depression – and that those long-hidden conditions are now killing people. Read full story Source: The Guardian, 13 September 2022
  12. News Article
    At least 12,000 people were treated for sepsis in hospitals in Ireland last year, with one in five of those dying from the life-threatening condition. However, the HSE said the total number of cases is likely to be much higher. Marking World Sepsis Day, it said the condition kills more people each year than heart attacks, stroke or almost any cancer. The illness usually starts as a simple infection which leads to an “abnormal immune response” that can “overwhelm the patient and impair or destroy the function of any of the organs in the body”. Dr Michael O’Dwyer, the HSE’s sepsis clinical lead, said: “The most effective way to reduce deaths from sepsis is by prevention. “A healthy lifestyle with moderate exercise, good personal hygiene, good sanitation, breastfeeding when possible, avoiding unnecessary antibiotics and being vaccinated for preventable infections all play a role in preventing sepsis. “Early recognition and then seeking prompt treatment is key to survival. Recognising sepsis is notoriously difficult and the condition can progress rapidly over hours or sometimes evolve slowly over days.” Read full story Source: Independent Ireland, 13 September 2022 hub resources on sepsis RCNi: Sepsis resource collection NSW Clinical Excellence Commission - Sepsis toolkit Dr Ron Daniels video: Recognising sepsis Introducing the Suspicion of Sepsis Insights Dashboard
  13. News Article
    Merope Mills’s recent article in the Guardian should be mandatory reading for all medical and nursing students. All of us who are senior doctors or nurses will recognise only too well the dangerous conditions that Merope describes: the senior doctors with overinflated egos; the internecine warfare between departments; the nursing staff and junior doctors who are rendered impotent by repeated attempts to galvanise action from off-site but know-it-all seniors; the lack of integrated thinking that results when there is no consistent lead clinician; and, most dangerous, not listening to the patient or their relatives, and not directly examining the patient. Candour and co-production are terms much used in healthcare, but for some staff these aspects of care are a million miles away from the ego-driven practice in which they engage. This is why Merope’s advice is so important. Do not have blind faith in your clinician. Do not leave all the thinking to them. Do equip yourself with knowledge and, most of all, do demand to be treated as an equal partner in the care of your body or your loved one. Current and former healthcare professionals respond to Merope Mills’s account of losing her daughter after a series of catastrophic medical errors. Read full story Source: The Guardian, 11 September 2022
  14. News Article
    More than 350 families have already contacted a review team which is examining failings at maternity units in two Nottingham hospitals. The review was opened on 1 September by Donna Ockenden, who previously led an inquiry into the maternity scandal at Shrewsbury and Telford NHS Trust. She will examine how dozens of babies died or were injured in Nottingham. Nottingham University Hospitals NHS Trust has apologised for "unimaginable distress" caused by its failings. More affected families, as well as staff with concerns, have been asked to come forward. Ms Ockenden said: "We are really pleased with the large numbers of families and staff that have already come forward in the first week of the review, and we actively encourage others to do the same." Read full story Source: BBC News, 12 September 2022
  15. News Article
    Excess deaths in the UK have continued to soar, as Covid deaths decreased for fourth week in a row, the latest data shows. A total of 10,942 deaths from all causes were registered in England and Wales in the week to 26 August, according to the Office for National Statistics. This is 16.6%above the five-year average, the equivalent of 1,556 “excess deaths” during this week. However, new figures show a continued downward trend in deaths involving Covid-19, which have fallen to the lowest level since the beginning of July. A total of 453 deaths registered in the seven days to August 26 mentioned coronavirus on the death certificate, according to the Office for National Statistics (ONS) – down 18 per cent on the previous week. Stuart Macdonald, from the Covid-19 actuaries’ response group, wrote: “There have been around 5,300 deaths with Covid-19 mentioned on the death certificate in the last ten weeks. Covid was the underlying cause for 3,400 of these and may also have contributed to others. Since Covid does not explain all the recent excess we need to look at other causes.” Mr Macdonald outlined a number of potential drivers of excess deaths which included increased risk of heart failure in people following Covid-19 infection, delays for urgent treatment within the NHS and missed or delayed diagnoses earlier in the pandemic. Read full story Source: The Independent, 6 September 2022
  16. News Article
    Guidelines for confirming death in very young babies are being reviewed amid concerns about a case in which a baby boy started to breathe after a diagnosis of brain stem death. Guy’s and St Thomas’ NHS Foundation Trust applied to the High Court in June for a declaration that A, who was born in April, was dead and for authorisation to withdraw his ventilation, ancillary care, and treatment. Aged 2 months, he had sustained a profound hypoxic ischaemic brain injury after a cardiac arrest that happened shortly after he was found limp in his cot with abnormal breathing. But before the case came to court a nurse observed him breathing spontaneously, and the trust rescinded the declaration of brain stem death. Read full story (paywalled) Source: BMJ, 31 August 2022
  17. News Article
    Cold homes will damage children’s lungs and brain development and lead to deaths as part of a “significant humanitarian crisis” this winter, health experts have warned. Unless the next prime minister curbs soaring fuel bills, children face a wave of respiratory illness with long-term consequences, according to a review by Sir Michael Marmot, the director of University College London’s Institute of Health Equity, and Prof Ian Sinha, a respiratory consultant at Liverpool’s Alder Hey children’s hospital. Sinha said he had “no doubt” that cold homes would cost children’s lives this winter, although they could not predict how many, with damage done to young lungs leading to chronic obstructive pulmonary disease (COPD), emphysema and bronchitis for others in adulthood. Huge numbers of cash-strapped households are preparing to turn heating systems down or off when the energy price cap increases to £3,549 from 1 October, and the president of the British Paediatric Respiratory Society, also told the Guardian that child deaths were likely. “There will be excess deaths among some children where families are forced into not being able to heat their homes,” said Dr Simon Langton-Hewer. “It will be dangerous, I’m afraid.” Read full story Source: The Guardian, 1 September 2022
  18. News Article
    The mother of a seven-year-old girl who died at Perth Children's Hospital says she pleaded with staff to help her daughter but was not taken seriously. Aishwarya Aswath died in April last year after attending the Perth Children's Hospital (PCH) with a high temperature and cold hands. The Perth Coroner's Court on Wednesday heard a statement from Aishwarya's mother Prasitha Sasidharan, who described how she grew increasingly worried about her daughter while in the hospital waiting room. She approached staff five times while they were in the waiting room for almost two hours. "I feel like I was ignored and not taken seriously," she said. The court heard from both parents on Wednesday, the start of an eight-day inquest. After Aishwarya died her father wanted to hold her but was only allowed to do so for a brief time. In his statement, read to the court, he said there were "many missed opportunities to save her." Former PCH chief executive Aresh Anwar said the hospital was grappling with a rise in mental health presentations and a shortage of staff when Aishwarya died. Read full story Source: ABC News (24 August 2022)
  19. News Article
    The families of any NHS and social care staff who died from Covid in the most recent waves will not be eligible for the Covid death assurance scheme launched at the start of the pandemic, it has emerged. The scheme closed on 31 March, despite pleas from the Royal College of Nursing (RCN) to keep it open. Since it was set up in April 2020, it has paid out £60,000 lump sums to the estates of 688 workers. A further 42 cases have been declined and 29 applications are still being processed. The RCN wrote to then health and social care secretary Sajid Javid on 30 March, calling for the scheme to be extended. General secretary and chief executive Pat Cullen wrote: “The over-riding principle must be that no member of nursing staff who loses their life this year should be afforded any less respect and family support than one who died in 2020 or 2021… “With a distinct possibility of new variants at any point, staff deserve assurance that they and their loved ones will not go unnoticed should they contract and ultimately lose their life to covid.” Read full story (paywalled) Source: HSJ, 19 August 2022
  20. News Article
    On Monday, September 20, 2021, Michael Wysockyj felt unwell and did what any gravely sick person would do: he put his life in the hands of the ambulance service. The 66-year-old from Norfolk was whisked by paramedics to the Queen Elizabeth hospital in King’s Lynn at 6.28pm. Nearly four hours later, he was still trapped inside the vehicle. The hospital was too full to take him. He died at 4.42am. So great were the concerns of the coroner, Jacqueline Lake, that she took the unusual step of issuing a “prevention of future death” notice. “The emergency department was busy at the time and unable to offload ambulances,” she said in her report. “An x-ray cannot be carried out in an ambulance and must wait until the patient is in [the emergency department].” This episode should be an anomaly in the failure of emergency services. It is not. The crisis is “heartbreaking”, according to Dr Ian Higginson, vice-president of the Royal College of Emergency Medicine. “If you call for an ambulance and you’re waiting many hours for one and you have a serious condition, that is going to have an impact on your outcome. It would be reasonable to assume the long delays that patients are subjected to waiting for ambulances at the moment will filter through into excess mortality.” Read full story (paywalled) Source: The Times, 21 August 2022
  21. News Article
    Britain is in the grip of a new silent health crisis. For 14 of the past 15 weeks, England and Wales have averaged around 1,000 extra deaths each week, none of which are due to Covid. If the current trajectory continues, the number of non-Covid excess deaths will soon outstrip deaths from the virus this year. Experts believe decisions taken by the Government in the earliest stages of the pandemic – policies that kept people indoors, scared them away from hospitals and deprived them of treatment and primary care – are finally taking their toll. Prof Robert Dingwall, of Nottingham Trent University, a former government adviser during the pandemic, said: “The picture seems very consistent with what some of us were suggesting from the beginning. “We are beginning to see the deaths that result from delay and deferment of treatment for other conditions, like cancer and heart disease, and from those associated with poverty and deprivation. “These come through more slowly – if cancer is not treated promptly, patients don't die immediately but do die in greater numbers more quickly than would otherwise be the case.” Read full story (paywalled) Source: The Telegraph, 18 August 2022
  22. News Article
    A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022
  23. News Article
    The midwife leading a review into Nottingham's maternity services has urged families and staff to come forward with their experiences. Donna Ockenden was appointed in May to head the inquiry into the services at Queen's Medical Centre and City Hospital. It was launched after more than 100 families with experiences of maternity failings wrote to former Health Secretary Sajid Javid demanding the action. A much-criticised initial review was subsequently scrapped. Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, said the review is now open to families, NHS workers and others who wish to contribute. "By September 1 we'll be ready to receive contact from families," she told Nottinghamshire Live. "In the mean time if there are either families or members of the NHS that want to get in touch they can use our new email. And also those who represent communities, whether that's safe communities or women's groups in Nottingham." People can contact the review through the email nottsreview@donnaockenden.com, which was launched last week. Ms Ockenden said that positive steps were being made in putting in place the "building blocks" for the review, which is due to start on 1 September 2022. Read full story Source: Nottinghamshire Live, 17 August 2022
  24. News Article
    Department of Health and Social Care (DHSC) officials are concerned that many more people are dying than expected in recent months – particularly older working-age people – with NHS care delays and interruptions a likely cause. HSJ understands there is concern and analysis under way across the chief medical officer’s team and in the Office for Health Improvement and Disparities. The DHSC told HSJ initial work showed the biggest causes of the “excess deaths” were cardiovascular disease (heart attacks and strokes) and diabetes. This supports the case they are being caused by a combination of the current very long delays for ambulances and other emergency care, and by people with heart disease and diabetes missing out on routine checks due to Covid and its knock-on effects, HSJ was told. Read full story (paywalled) Source: HSJ, 17 August 2022
  25. News Article
    Senior doctors have raised concerns about the numbers of patients now dying in their A&E department due to extreme operational pressures. HSJ has seen an internal memo sent to staff at Royal Albert Edward Infirmary in Wigan, which warns it is becoming “increasingly common” for patients to die in the accident and emergency department. The memo suggests the department has reported five deaths in the latest weekly audit, when it would normally report one or two fatalities. The memo said: “Of the 72 patients in A&E as I write this, 16 have been there over 24 hours and 34 over 12 hours. The longest stay is almost 48 hours… “It’s becoming increasingly common to die in A&E. We have included A&E deaths [in weekly audits] for the last 4 years. They used to be 1 or 2. This week there were 5. They used to die at or just after arrival, but that’s changing too… “There is every reason to think winter will be worse.” The memo echoes warnings made by numerous NHS leaders in recent months around the intense service pressures and an increased risk of incidents and mistakes. Read full story (paywalled) Source: HSJ, 17 August 2022
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