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News ArticleThe UK had one of the worst increases in death rates of major European economies during the Covid pandemic, BBC analysis has found. Death rates in the UK were more than 5% higher on average each year of the pandemic than in the years just before it, largely driven by a huge death toll in the first year. That was above the increase seen in France, Spain or Germany, but below Italy and significantly lower than the US. It would take many inquiries to tease apart the effect of all the possible reasons behind every nation's pandemic outcomes: preparedness, population health, lockdown timing and severity, social support, vaccine rollout and health care provision and others. But some argue that there are lessons for the UK that need to be learned even before we think about future pandemics. The UK's heavy pandemic death toll "built on a decade of lacklustre performance on life expectancy" says Veena Raleigh, of the King's Fund, a health think tank. She argues that government action to improve population health and turn that around has "never been more urgent. Read full story Source: BBC News, 22 June 2023
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News ArticleThe family of a man who died after being given infected blood have called on the UK government to pay their compensation immediately. Randolph Peter Gordon-Smith, who had haemophilia, learned in 1994 that he had been infected with hepatitis C. His daughter said the family were "abandoned" to care for him without support before his death in 2018. The chairman of the UK infected blood inquiry has said parents and children of victims should receive compensation. Sir Brian Langstaff wants to see a final compensation framework set up by the end of the year. Ms Gordon-Smith, who lives in Edinburgh, says compensation would provide an acknowledgement of "what they did to our family" as his daughters cared for him when he was dying. "I think the government needs to get their chequebook out, do the right thing and pay [the compensation]," she added. "Not when the inquiry rules, but now." Read full story Source: BBC News, 22 June 2023
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News ArticleA warning has been made over the possible side effects of a common NHS antibiotic by a coroner after a newly retired senior doctor died by suicide. "Respected and experienced" consultant cardiologist Robert Stevenson had no history of depression or mental health problems before he started a course of ciprofloxacin. But just over a week later, the 63-year-old went for a walk and messaged his wife to tell her he had left a note under his pillow. He was later found dead in a nearby wood. The note he had left was said to be "uncharacteristically confused and illogical" with "baseless concerns" that he might have AIDS after taking an online HIV tester kit, an inquest heard. The hearing was told Dr Stevenson hadn't been told about a "potential rare link" to suicidal behaviour in patients who took the drug, as this wasn't in line with medical guidance. Now, coroner Martin Fleming issued a warning to highlight the risk of taking the antibiotic, which is prescribed by the health service for serious conditions. Read full story Source: The Mirror, 20 June 2023
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News Article“Stop killing us,” protesters across Poland chanted this evening, demanding the legalisation of abortion, after reports reached the media of a pregnant woman’s death in a hospital in May. On Monday, Poland’s patients’ rights ombudsman, Bartłomiej Chmielowiec, said that the John Paul II hospital should have told 33-year-old Dorota Lalik that her life could be saved through an abortion. The hospital violated her rights by withholding the information, the ombudsman ruled. The woman died in the hospital in Nowy Targ, in the south of the country, on 24 May, three days after her admission. “No one told us that we had practically no chance for a healthy baby … The entire time they were giving us false hope that everything will be OK … that [in the worst case] the child will be premature,” Lalik’s husband told Polish media. “No one gave us the choice or the chance to save Dorota, because no one told us her life was at risk.” Read full story Source: The Guardian, 14 June 2023
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News Article
NHS 'corrected mistakes' after son's suicide
Patient Safety Learning posted a news article in News
An NHS trust has been accused of adding to the records of a man the day after he took his own life to "correct their mistakes". Charles Ndhlovu, 33, died under the care of Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) in 2017. Mr Ndhlovu, who was diagnosed with paranoid schizophrenia and substance misuse, had been under CPFT's care two months when he died. He had been transferred from a neighbouring trust after moving to Ely and then been taken off a community treatment order. His mother, Angelina Pattison, told the BBC that despite being heavily involved in her son's care, she was "shocked that they transferred him without even telling me". A trust serious untoward incident (SUI) review acknowledged that when he was transferred no-one from CPFT had asked about whether his family had been involved in his care. Ms Pattison said: "They didn't have any address of [my home] in his care plan and the care plan was done when he died - when they were running around to correct their mistakes, which they have done" The BBC has separately spoken to consultant nurse and psychotherapist Des McVey, who was asked by the trust to investigate a complaint in July 2021, understood to be the one from Ms Pattison. Mr McVey said: "I noticed that the deceased did have care plans, but they were written the day after his death and they were also evaluated the day after his death and I was concerned that this wasn't picked up by the SUI." He said this "really alarmed me", adding: "Surprisingly, there was no care plan to address his suicidal ideation and he had... an extensive history of trying to kill himself." Read full story Source: BBC News, 15 June 2023 . -
News Article
New triage policy implicated in 44-year-old’s death
Patient Safety Learning posted a news article in News
An ambulance service says it has sped up clinical review of lower-priority calls, after a coroner said the new triage process — introduced in response to recent waiting time pressures — ‘will lead to further deaths’. The coroner raised concerns with West Midlands Ambulance Service after a type 1 diabetic patient died following a long delay in deciding whether to send an ambulance. Following a pilot in July 2021, all category 3 and 4 incidents at WMAS, except for a predefined list of exceptions, are sent directly to the trust’s “clinical validation team” to triage patients, with the aim of reducing the need for ambulance call-outs. It is thought a similar approach has been introduced across England since covid, as there have been huge pressures on ambulance capacity. But coroner Emma Serrano has raised concerns about the process in a prevention of future deaths report published this week. The inquest was told that Ms Finch waited 10 hours for her call to be “clinically assessed” and an ambulance call-out approved as the validation team was “under-staffed”. The PFD report also said that there was “no time limit” for assessments to take place, and no prioritisation system. Read full story (paywalled) Source: HSJ, 14 June 2023 -
News Article
Health officials ‘ignored evidence of non-Covid deaths’ during lockdown
Patient Safety Learning posted a news article in News
The Covid inquiry is being urged to investigate if health officials dismissed evidence of collateral deaths during lockdown after a whistleblower claimed that pathologists’ concerns were shut down. As the inquiry prepares to hold its first full public hearing this week, Prof Sebastian Lucas, who worked as a consultant pathologist at St Thomas’ Hospital in London, claimed that PHE was not interested in what he described as “collateral deaths”. Prof Lucas wrote to Prof Kevin Fenton, the director of PHE London, on behalf of the London Inner South Jurisdiction Pathology Advisory Group. He approached the agency in January 2021 as the UK entered its third lockdown, warning that collateral deaths as a result of the pandemic had not been recorded properly. The group, which was headed up by a coroner, had identified several deaths that would not have happened had the NHS been functioning as normal. This included people who did not want to bother the doctor or who took their own lives because of lockdowns. Read full story (paywalled) Source: The Telegraph, 10 June 2023 -
News Article
Covid inquiry prepares for first hearing after 220,000 deaths
Patient Safety Learning posted a news article in News
More than three years after Boris Johnson announced a nationwide lockdown, the Covid investigation will cover every aspect of the UK’s pandemic response. More than three years after the first lockdown began, two years after the last one ended, the public hearings are at last starting. Over the months that come the inquiry will have many questions to answer. Should we have locked down earlier? Should we have not locked down at all? Did we eat out to help restaurants out, or eat out to help the virus out? Could more have been done to protect care homes from infection? Should more have been done to protect residents from loneliness? Baroness Hallett, the judge presiding, said her chief role is “to determine whether [the] level of loss,” in the broadest sense of the word, “was inevitable or whether things could have been done better”. Read full story (paywalled) Source: The Times, 13 June 2023 -
News Article
Nearly one in five of world’s newborns with sepsis die, study finds
Patient Safety Learning posted a news article in News
A study in 11 countries over four continents has shown the “catastrophic impact” of antibiotic resistance on babies with sepsis, with nearly one in five dying. The two year observational study enrolled 3204 babies with clinical sepsis in 19 hospitals in Africa, Asia, Europe, and Latin America. It found that 17.7% were blood culture pathogen positive, and mortality rates among infants up to 60 days old with culture positive sepsis was 17.7%. The research, published in PlOS Medicine, also highlighted wide variation in treatment and frequent switching of antibiotics because of resistance, with 206 antibiotic combinations used by the hospitals studied in Bangladesh, Brazil, China, Greece, India, Italy, Kenya, South Africa, Thailand, Vietnam, and Uganda. Read full story Source: BMJ, 9 June 2023 -
News ArticleInquests will be held into the deaths of at least 36 patients – and potentially dozens more – treated by the jailed former breast surgeon Ian Paterson. As the fallout of one of the most horrific medical scandals in the history of the NHS continues, a pre-inquest review hearing at Birmingham and Solihull coroner’s court on Friday heard that 417 of Paterson’s cases where breast cancer was listed as the immediate cause of death had been examined. Paterson, who attended the hearing remotely from prison, was sentenced to 15 years in jail in 2017, later increased to 20 years, for carrying out needless surgery on patients who were left traumatised and scarred. Inquests have been confirmed in 36 cases, with a further 21 cases deemed likely to need an inquest after “preliminary” investigations. Another 36 cases are still to be reviewed. The judge Richard Foster said a further 130 cases had been reported to the coroner where breast cancer was listed as contributing to death. A review of a selection of those cases was being carried out and a decision on whether they should all be reviewed would be made on its completion, he said. Read full story Source: The Guardian, 9 June 3023
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News ArticlePolice are investigating about 40 hospital deaths over allegations of medical negligence made by two consultant surgeons who lost their jobs after blowing the whistle about patient safety. The allegedly botched operations took place at Royal Sussex County hospital (RSCH) in Brighton, part of University hospital Sussex NHS trust, when it was run by a management team hailed by Jeremy Hunt as the best in the NHS. Last week, detectives from Sussex police wrote to the trust’s chief executive, George Findlay, confirming they had launched a formal investigation into “a number of deaths” at the RSCH. They were investigating allegations of “criminal culpability through medical negligence” made by “two separate clinical consultants” at the trust, the letter said. It is understood about 40 deaths occurred between 2015 and 2020 after alleged errors in general surgery and neurosurgery departments. Both whistleblowers alleged the trust failed to properly investigate the deaths and learn from the mistakes made. Read full story Source: The Guardian, 9 June 2023
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News ArticleOne of the NHS’ largest hospital trusts is being investigated over “possible gross negligence manslaughter” after a baby died 24 hours after her birth. Polly Lindop died at St Mary’s Hospital on 13 March and Greater Manchester Police have now launched a probe into her death. Police said its major incident team launched the investigation into “possible Gross Negligence manslaughter” after concerns were raised to the force and local coroner. DCI Mark Davis of GMP’s major incident team said: “First, I want to express my condolences to the parents of Polly at what is an extremely difficult time for them. Our thoughts will remain with them as we carry out our investigation. “A number of hospital staff have been spoken to as witnesses by officers and no arrests have been made at this time. “The hospital trust has been fully cooperative with the police and all relevant authorities have been kept informed. The investigation into Polly’s death is on-going and her family will continue to be kept updated in relation to any significant developments.” Read full story Source: The Independent, 5 June 2023
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News ArticlePatients diagnosed with cancer in 2020 had “significantly lower” survival rates in Scotland a year after having their cases confirmed compared with the previous year, a report has found. The increase in deaths was an indirect result of the pandemic as coronavirus dissuaded people from getting check-ups or visiting physicians. Many cancer screening programmes were also paused and infection control measures in healthcare settings caused delays in both diagnosis and treatment. Andrew Elder, president of the Royal College of Physicians, said the government’s decision to pause screening programmes was “understandable in the extreme circumstances”, but added that the figures were “concerning”. He said: “Fewer and later presentations by patients who may have had more advanced disease clearly have had sometimes tragic consequences that are now being identified in the data.” Read full story (paywalled) Source: The Times, 31 May 2023
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News Article
CQC case reveals ‘degrading’ conditions in England care home as Covid hit
Patient Safety Learning posted a news article in News
The depth of suffering in care homes in England as Covid hit has been laid bare in a court case exposing “degrading” treatment with residents being “catastrophically let down”. Care levels at the Temple Court care home in Kettering collapsed so badly in April 2020, when ministers rushed to free up NHS capacity by discharging thousands of people, that residents were left lying in their own faeces, dehydrated, malnourished and suffering necrotic, infected wounds, the Care Quality Commission found. Fifteen of its residents died with Covid in the first weeks of the pandemic. The case foreshadows the UK Covid-19 public inquiry module on the care sector, which next year will test Matt Hancock’s claim to have thrown “a protective ring around social care”. The prosecution resulted in a £120,000 fine handed down at Northampton magistrates court last week. The operator, Amicura, apologised but said it had been “acting in the national interest and supporting the NHS by accepting patients discharged from hospitals into care homes under government policy”. Read full story Source: The Guardian, 29 May 2023 -
News Article
Child died at mental health hospital ‘while staff were meant to be watching her’
Patient Safety Learning posted a news article in News
A 14-year-old girl who should have been under constant supervision at a mental health hospital died after a member of staff on his first shift left her unattended, an inquest has heard. Ruth Szymankiewicz died at Taplow Manor Hospital in Maidenhead on 12 February 2022 after a care worker responsible for her one-to-one supervision “sporadically” left his post, the hearing was told. It also emerged at the hearing that the care worker, who is now abroad, was allegedly using a fake name. Detectives are investigating him as part of a fraud investigation although he has not yet been interviewed by police. After Ruth’s death, the Care Quality Commission launched a criminal investigation. In an update to the coroner, it said that the investigation was looking at whether the provider had “brought about avoidable harm or exposure to risk” in relation to the young girl’s death. Read full story Source: The Independent, 26 May 2023 -
News Article
Closing baby unit considered over safety concerns
Patient Safety Learning posted a news article in News
Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023 -
News Article
Woman died on floor after waiting over five hours for ambulance in Wales
Patient Safety Learning posted a news article in News
A 58-year-old woman died alone curled up in a blanket on the floor of her bedroom as she waited more than five hours for an ambulance. Relatives of Rachel Rose Gibson believe she had a heart attack at her home in Wrexham, north Wales, only a short drive away from a hospital, but died before an ambulance reached her. The Welsh ambulance service said that on the day Gibson died, its crews spent more than 700 hours waiting outside hospitals for patients to be admitted, which meant they could not respond quickly to people needing help. Family members said Gibson, a grandmother of seven, called an ambulance at 4pm on 5 April as she was coughing up blood and in chronic pain. By the time an ambulance arrived at 9.30pm, she had died. Her daughter, Nikita, 29, said: “She was lying on the floor curled up in a blanket. It haunts me to know she died alone in so much pain. “I feel like I can’t fully grieve because I’m so angry. She only lives five minutes away from the hospital, but must have been in too much pain to get into a taxi.” Read full story Source: The Guardian, 22 May 2023 -
News ArticleAbout 23,000 people died in accident and emergency departments last year, according to an estimate by Labour based on Freedom of Information requests to every NHS trust in England. Half of the trusts responded to the party’s requests and, based on that information, it calculated that just over 23,000 people had died – an increase of more than 20% on 2021, and nearly 40% on 2020. The increase in deaths corresponds with a sharp rise in NHS waiting times, as hospitals struggle with high demand and a lack of resources after the Covid-19 pandemic. Wes Streeting, the shadow health secretary, said: “People turning to the NHS in an emergency should know they will be seen and treated before it’s too late. The Conservatives’ failure over 13 years to properly staff or reform the NHS has a cost in lives.” Maria Caulfield, the health minister, defended the government’s record, however, saying: “We are delivering a record number of tests, speeding up discharge from hospitals, and cutting waiting lists as we also work to halve inflation, grow the economy, reduce debt, and stop the boats.” Read full story Source: The Guardian, 19 May 2023
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News Article
Labour vows to reverse rise in suicides in England and Wales within five years
Patient Safety Learning posted a news article in News
A Labour government would reverse the rise in the number of deaths from suicide as part of a health plan to replace pain and anxiety with a “hope of a renewed NHS”, Keir Starmer will pledge. In a speech today, the Labour leader will say his plan for reforming the NHS will focus on the biggest causes of death in the UK including suicide. He will point to coroners’ statistics showing that deaths from suicides have been rising since 2008, and reached a record high last year in England and Wales. If the party takes power Labour will reverse this rise within five years, Starmer will say. A segment of his speech previewed by the party says: “Suicide is the biggest killer of young lives in this country. The biggest killer. That statistic should haunt us. And the rate is going up. Our mission must be and will be to get it down.” Labour has not provided details on how it proposes to meet this pledge other than an aspiration to shift from “sickness to prevention”. Starmer will also propose introducing new NHS targets on cutting deaths in England from heart disease and strokes by a quarter over 10 years. Read full story Source: The Guardian, 21 May 2023 -
News Article
Warning as baby dies and seven more fall critically ill with ‘usually mild virus’
Patient Safety Learning posted a news article in News
A baby has died and seven others were left requiring intensive care after a “usually mild” virus appeared to trigger a serious heart condition, health officials have said. The World Health Organization (WHO) said it had been notified of an “unusual” increase in myocarditis –inflammation of the heart – among newborns in south Wales infected with an enterovirus over the past year. While enteroviruses are common and often asymptomatic, they are known to cause “occasional outbreaks in which an unusually high proportion of patients develop clinical disease, sometimes with serious and fatal consequences – in this instance myocarditis”, the UN health agency said. While prior to the recent cluster of cases, south Wales had experienced only two similar cases in six years, the 10 months to April saw 10 cases of myocarditis in babies under the age of 28 days who tested positive for enterovirus, according to WHO. Read full story Source: The Independent, 19 May 2023 -
News Article
Gosport hospital drug deaths: Police identify 19 suspects
Patient Safety Learning posted a news article in News
Nineteen suspects have been identified by police as part of a new inquiry into hundreds of deaths at a hospital. An independent panel found 456 patients died after being given opiates inappropriately at Gosport War Memorial Hospital between 1987 and 2001. The new criminal investigation is being led by Kent Police after three previous ones by Hampshire Constabulary resulted in no prosecutions. Police said interviews with the suspects under caution were ongoing. Detectives are examining more than 750 patient records as part of Operation Magenta after families, who have also campaigned for judge-led "Hillsborough-style" inquests, repeatedly called for justice. Read full story Source: BBC, 17 May 2023 -
News ArticleMore than 26,000 adults with severe mental illness die prematurely each year from preventable physical illnesses, analysis by the Royal College of Psychiatrists suggests. New data from the Office for Health Improvement & Disparities shows 120,273 adults in England with severe mental illness, including psychosis, post-traumatic stress disorder and schizophrenia, died before the age of 75 between 2018 and 2020. Of these, the College estimates 80,182 deaths (two in three) were potentially preventable, which is an average of 26,727 people each year. Preventable deaths include deaths from diseases like cancer and heart disease which could have been prevented with earlier detection and treatment or lifestyle changes. While adults with severe mental illness are more likely to engage in unhealthy behaviours like smoking and drinking alcohol excessively, they are also less likely to access screening and treatment for a range of reasons including stigma associated with having a mental illness. While cancer is the leading cause of premature death among those with a severe mental illness, it also significantly increases the risk of dying before the age of 75 across a range of physical health conditions. Adults with severe mental illness are on average: 6.6 times more likely to die prematurely from respiratory disease 6.5 times more likely to die prematurely from liver disease 4.1 times more likely to die prematurely from cardiovascular disease 2.3 times more likely to die prematurely from cancer. Read full story Source: Royal College of Psychiatrists, 17 May 2023
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News Article
Do not resuscitate: Man choked to death after paramedics stood down
Patient Safety Learning posted a news article in News
Experts are calling for "do not resuscitate" orders to be scrapped, saying they are being misused and putting people's lives at risk. One woman told BBC News that her elderly father might still be alive if the DNR in his medical file had been properly checked. When Robert Murray began choking on a piece of fruit at breakfast, staff at his care home called 999. He'd stopped breathing and the ambulance service operator immediately sent paramedics to attend. But seconds later, the care home told the dispatcher that the 80-year-old had a do not resuscitate form (DNR) in his medical records. The paramedics were stood down. Mr Murray died minutes later. However, it was all a terrible mistake. It hadn't been made clear to the ambulance service that Mr Murray was choking - the DNR was only meant to apply should he have a cardiac arrest. Mr Murray's death, at a nursing home in Eastbourne in June 2021, is an example of what experts call "mission creep" in the use of DNR - also known as DNACPR (Do Not Attempt Cardiac Pulmonary Resuscitation) - decisions. Researchers from Essex University say some care home residents are "being inappropriately denied transfer to hospital or access to certain medicines" due to the recommendations. Read full story Source: BBC News, 16 May 2023 -
News Article
Babies are dying because of NHS failings, poverty and inequality, charities warn
Patient Safety Learning posted a news article in News
Hundreds of babies are dying unnecessarily because overstretched maternity services are delivering substandard care and struggling to overcome entrenched poverty and racial inequalities, a report has warned. The report by baby loss charities Sands and Tommy’s says the government’s aim to halve the number of stillbirths and neonatal deaths in England by 2025 is stalling, while there is no target in Scotland, Wales or Northern Ireland. Stillbirths are creeping up in England after falling in the past decade. Babies dying before and during delivery rose to just over four in every 1,000 births in 2021. Similarly, long-falling rates of neonatal deaths, where newborns die within the first four weeks of birth, are also rising. There were 1.4 deaths of newborn babies for every 1,000 births in 2021, compared with 1.3 in 2020. Robert Wilson, head of the charities’ joint policy unit, said the government and NHS need to make fundamental changes. “The UK is not making enough progress to reduce rates of pregnancy loss and baby death, and there are worrying signs that these rates are now heading in the wrong direction,” he said. Read full story Source: The Guardian, 14 May 2023 -
News Article
Baby heart death parents left waiting 14 months for answers
Patient Safety Learning posted a news article in News
Grieving parents have been left waiting more than 14 months for answers about why their 12-day-old son died. Elijah was born at Merthyr Tydfil's Prince Charles Hospital on 25 February 2022 and died after being diagnosed with enterovirus and myocarditis. Joann and Christian Edwards said they were told they would have a report by the end of 2022, but are still waiting. Joann and Christian, from Mountain Ash, Rhondda Cynon Taf, said they were told Elijah's myocarditis was a "one off" but subsequently read about 10 babies, including one who died, getting severe enterovirus with myocarditis across south Wales. Public Health Wales (PHW) said Elijah's death was not being looked into as part of an investigation into this cluster of cases, as the dates were set at June 2022 to April 2023 to coincide with the enterovirus season. But it said it would look to include Elijah's death as part of a "wider clinical investigation" of the cases. Read full story Source: BBC News, 15 May 2023
