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News Article
Coroner warns of lack of change since man's death
Patient Safety Learning posted a news article in News
A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in a seclusion room, was transferred to a private room on the ward. Mr Harris was discovered unresponsive in bed during the early hours of 10 April and pronounced dead half an hour later. In a Prevention of Future Deaths Report (PFDR), Ms Lake said: "Quality audits undertaken following Eliot Harris's death, show that observations are still not being carried out and recorded in accordance with NSFT's most recent policy - more than two years following Eliot's death." She said that on the night Mr Harris died there was no nurse in charge and instead of being allocated specific tasks, staff were told to "muck in", causing confusion about job responsibilities. These issues were not resolved at the time of the inquest, she said, with no evidence provided about whether specific tasks were allocated on the night shift. Not all staff had been trained in recording observations, there was a lack of evidence about procedures for entering a patient's room over concerns for their welfare, and there was "still some way to go to make sure care plans are completed", Ms Lake said. Read full story Source: BBC News, 6 October 2022 -
News Article
WHO alert over India-made cough syrups after deaths in The Gambia
Patient Safety Learning posted a news article in News
A global alert has been issued over four cough syrups after the World Health Organization (WHO) warned they could be linked to the deaths of 66 children in The Gambia. The syrups have been "potentially linked with acute kidney injuries and 66 deaths among children", it said. The products were manufactured by an Indian company, Maiden Pharmaceuticals, which had failed to provide guarantees about their safety, the WHO added. The WHO identified the medicines as Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup. The four products had been identified in The Gambia, but "may have been distributed, through informal markets, to other countries or regions", the WHO added, in the alert published on its website. It warned that their use may result in serious injury or death, especially among children. Read full story Source: BBC News, 6 October 2022 -
News Article
How 175 British children were infected with HIV
Patient Safety Learning posted a news article in News
At least 175 children with the blood disorder haemophilia were infected with HIV in the 1980s, according to documents from the national archives seen by BBC News. Some of the families affected are giving evidence at a public inquiry into what has been called the worst treatment disaster in the history of the NHS. It was almost 36 years ago - in late October 1986 - but Linda will never forget the day she was told her son had been infected. She had been called into a consulting room in Birmingham Children's Hospital, with 16-year-old Michael. As a toddler, he had been diagnosed with haemophilia, a genetic disorder that stopped his blood clotting properly. Linda assumed the meeting was to discuss moving his care to the main Queen Elizabeth Hospital in the city. "It was so routine that my husband stayed in the car outside," she says. "Then, all of a sudden, the doctor said, 'Of course, Michael is HIV positive,' and he came out with it like he was talking about the weather outside. My stomach just fell." Between 1970 and 1991, 1,250 people with blood disorders were infected with HIV in the UK after taking Factor VIII - a new treatment that replaced the clotting protein missing from their blood. About half of those infected with HIV died of an Aids-related illness before life-saving antiretroviral drugs became available. Almost three decades later, Linda is giving evidence to the long-running public inquiry into the treatment disaster. She will appear alongside other parents, in a special session about the experiences of families whose children were infected in the 1970s and 80s. "I felt as though I needed to do it because I want to help get to the bottom of it," she says. "We all want to know why it was allowed to happen and to keep on happening as well." Read full story Source: BBC News, 6 October 2022 -
News Article
Residents 'not safe' at four-inquest care home
Patient Safety Learning posted a news article in News
A care home that will close after admitting "shortcomings in care" and failures in leadership has been labelled "not safe" by inspectors. The Elms in Whittlesey, Cambridgeshire will shut later this month, and the Care Quality Commission (CQC) has found the service to be inadequate. In May, the BBC first reported the concerns of relatives about The Elms after their loved ones died in 2019, weeks after a meeting in which worries were raised about "poor care". Inquests into the deaths of the residents - George Lowlett, Margaret Canham and David Poole - remain ongoing. HC-One also apologised to the family of Joyce Parrott, who died in April 2020. Inspectors found "people were not safe and were at risk of avoidable harm" and described multiple occasions when people had "not received their medicines as prescribed". Other findings included: Staff had not referred all potential safeguarding events to the local authority A failure to "establish systems to ensure people were effectively safeguarded from abuse" The provider had failed to learn when things went wrong "Widespread and significant shortfalls" in leadership No reliable record of the staff that had worked at the home and a reliance upon agency staff, which "resulted in people not receiving consistent care" Read full story Source: BBC News, 5 October 2022 -
News Article
Covid inquiry ‘marginalising’ bereaved on first day of hearing
Patient Safety Learning posted a news article in News
Bereaved families fear their experiences will be “diluted” in the UK Covid-19 Inquiry after it was confirmed their evidence would be submitted to a third-party company. Instead of the usual “pen portraits” heard in the inquiry, families will submit their evidence to a private research company as part of a parallel listening exercise that will analyse the responses and feed back the findings to the inquiry chaired by Baroness Heather Hallett. Matt Fowler, co-founder of the Covid-19 Bereaved Families for Justice campaign, said while families believe the start of the inquiry is a step in the right direction after campaigning for two years, they fear being excluded from the inquiry because of the listening exercise. “All bereaved families want from the inquiry is the same outcome that anyone should, for lessons to be learnt from our loss that can stop the monumental scale of death that took place from happening again,” Matt said following the preliminary hearing. “As Baroness Hallett herself has acknowledged, for that to happen the experiences of the bereaved must be learnt from, so why is she leaving us out in the cold instead of working with us?” A&E doctor Saleyah Ahsan, from east London, worked in intensive care units during the pandemic. She said she remembers holding hands with people and telling them they needed to be incubated as they desperately called their families – some died in intensive care. “It is very important that stories jump off the page and are real because they are real,” She added: “If we really want to make sure we get this right there is only this inquiry, it has to be right. I am a medic, I see the numbers are rising, it’s autumn. Thankfully we’ve got a booster but hospitals are getting busy – I’m worried.” Read full story Source: The Independent, 4 October 2022 -
News Article
Hospital merger confusion blamed for cancer deaths
Patient Safety Learning posted a news article in News
A ‘leading’ cancer service has reported a series of safety incidents which contributed to patients being severely harmed or dying, HSJ has reported. An internal report at Liverpool University Hospitals Foundation Trust suggests the incidents within the pancreatic cancer specialty were partly linked to patient pathways being ill-defined following the merger of its two major hospitals. The report lists seven incidents involving severe harm or death, and five involving moderate harm. It is not clear how many of the patients died. The trust was formed in 2019 through the merger of the Royal Liverpool and Aintree acute sites, with the consolidation of clinical services an integral part of the plans. However, there were no formal plans to change the configuration of pancreatic cancer services, which already operated under a “hub and spoke” model. In one finding relevant to all 12 incidents, the report said: “Patient ownership and clinician accountability (local vs specialist) have not been defined following the merger of the legacy trusts and subsequent service reconfigurations. “This has contributed to system failures in the provision of timely quality care, particularly in patients with time-critical clinical uncertainty.” Read full story (paywalled) Source: HSJ, 5 October 2022 -
News ArticleTina Hughes, 59, died from sepsis after doctors allegedly delayed treating the condition for 12 hours while they argued over which ward to treat her on. Ms Hughes was rushed to A&E after developing symptoms of the life-threatening illness on September 8 last year. Despite paramedics flagging to staff they suspected sepsis, it was not mentioned on her initial assessment at Sandwell General Hospital, in West Bromwich. A second assessment six hours later also failed to mention sepsis while medics disagreed over whether to treat her on a surgical ward or a high dependency unit. The grandmother-of-five was eventually transferred to the acute medical unit at 3am the next morning where sepsis was finally diagnosed, but she continued to deteriorate and was admitted to intensive care four hours later and put on a ventilator. She died the following morning. A serious incident investigation report by Sandwell and West Birmingham Hospitals NHS Trust has since found there was "a delay in explicit recognition of sepsis". Read full story (paywalled) Source: The Telegraph, 4 October 2022
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News Article
Tribunal told of 'failure' over girl's blood tests
Patient Safety Learning posted a news article in News
If doctors had tested a nine-year-old girl's blood sooner they may have changed the treatment she received before her death, an expert witness has confirmed to a medical tribunal. The hearing was told this was a "significant failure" in the care of Claire Roberts. Claire died at the Royal Belfast Hospital for Sick Children in 1996. In 2018 a public inquiry concluded she died from an overdose of fluids and medication caused by negligent care. At the time, her parents were told a viral infection had spread from her stomach to her brain. The General Medical Council (GMC) said one of the doctors involved in Claire's care, Dr Heather Steen, acted dishonestly in trying to conceal the circumstances of her death. Dr Steen denied allegations that she acted dishonestly and engaged in a cover-up. The Medical Practitioners Tribunal Service (MPTS) heard from a defence expert witness on Monday who said doctors not checking the sodium levels in Claire's blood earlier was a "significant failure" in her care. Dr Nicholas Mann told the tribunal he would have ordered more blood tests on Claire on the morning after she was admitted to hospital but he said he did not know if this would have prevented her death. "There should have been more attention to her fluids and electrolytes on the day after admission. Whether that would have altered the final outcome I don't know but certainly it would have been sensible to do that," he said. The tribunal also heard that Claire's death was not referred to a coroner, despite this being something all of the doctors caring for her would have had a duty to do. It was also told that a letter sent to Claire's parents from the hospital in 2005 contained inaccuracies. During questioning of Dr Mann, a barrister for the GMC highlighted the involvement of Dr Steen in compiling the letter which was signed by another doctor. Tom Forster KC said it was the GMC's case that Claire's family were given incorrect information about potential causes of her death despite these not being definitively diagnosed. Read full story Source: BBC News, 3 October 2022 -
News Article
Covid inquiry first preliminary hearing to begin
Patient Safety Learning posted a news article in News
The first preliminary hearing of the UK Covid public inquiry will begin today. The session, in London, will focus on the UK's pandemic preparedness before 2020. It will be largely procedural, involving lawyers and an announcement about who will be giving evidence. Public hearings where witnesses are called will not start until the spring. The inquiry formally started in the summer, with a listening exercise. But this first preliminary hearing is still being seen as an important milestone for the families who lost loved ones. Lindsay Jackson's mother, Sylvia, 87, died from Covid during the first lockdown, after contracting it at a care home. Ms Jackson, of the Covid-19 Bereaved Families for Justice campaign group, said it was essential lessons were learned. She was "really pleased" the inquiry was finally starting but it had taken too long to reach this stage. "It's two-and-a-half years since the pandemic started," she said. "We lost so many people. If people have done things wrong, they need to be held accountable. "For me, my family and the others who lost loved ones, it's important that answers are found to the questions that we have." Read full story Source: BBC News, 4 October 2022 -
News ArticleHospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022
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News Article
Scottish Government orders review as neonatal deaths higher than expected
Patient Safety Learning posted a news article in News
Healthcare Improvement Scotland have been commissioned to lead a review into the neonatal death rates. It follows the higher than expected deaths in both March 2022 and September last year, as published by Public Health Scotland. At least 18 babies under four weeks old died in March – a rate of 4.6 per 1,000 births. The wider inquiry is understood to have been triggered because the mortality rate passed an "upper control" threshold of 4.4 per 1,000 births. The average mortality rate among newborns is just over 2 per 1,000 births. The Scottish Government said the investigation is expected to take no longer than six to nine months once the review team is formed. Public health minister Maree Todd said: “Every death is a tragedy for the families involved. That is why earlier this year I committed to this review to find out if there is a reason for the increase. “I appreciate how difficult this time is for anyone affected and I would encourage them to access support if they wish to do so. There is information about organisations and help available on the National Bereavement Care Pathways Scotland as well as the Scottish Government website.” Read full story Source: The Scotsman, 30 September 2022 -
News Article
Mother given substantial damages over baby's care
Patient Safety Learning posted a news article in News
A mother from County Down will receive "substantial" undisclosed damages over alleged hospital treatment failures and care given to her daughter. Christina Campbell from Ballygowan brought medical negligence lawsuits over treatment she received at the Ulster Hospital in Dundonald after her daughter, Jessica, died in 2017 with a rare genetic disorder. The claim said that failure to test Ms Campbell during her pregnancy meant the condition went undetected. Damages were also sought for an alleged "ineffective" end of life care plan for the four month old. Jessica was diagnosed with trisomy 13 shortly after her birth in December 2016. She experienced feeding and respiratory difficulties, as well as a congenital heart defect and a bilateral cleft lip and palate. She was discharged from hospital with a home-based end-of-life care plan, including community and respite referral to the hospice, but a few months later. The claims said a failure to provide Ms Campbell with a amniocentesis test, which checks for genetic or chromosomal conditions, meant Jessica's condition was not discovered sooner. The lawsuit also highlighted concerns about Jessica's hospice treatment. It includes alleged uncertainty about the provision of humidified oxygen, a defective feeding pump and delays in a specific feeding plan and saline nebuliser being provided for the family. The family's solicitor said the awarding of damages "signifies the importance of lessons learned" as a result of Ms Campbell's campaign. "It is hoped that lessons can now be learned to ensure no other family has to go through a similar experience," he said. Read full story Source: BBC News, 29 September 2022 -
News Article
NHS 111 failures led to early Covid deaths, investigation finds
Patient Safety Learning posted a news article in News
Multiple failures by the NHS 111 telephone advice service early in the pandemic left Covid patients struggling to get care and led directly to some people dying, an investigation has found. The Healthcare Safety Investigation Branch (HSIB) looked into the help that NHS 111 gave people with Covid in the weeks before and after the UK entered its first lockdown on 23 March 2020. It identified a series of weaknesses with the helpline, including misjudgment of how seriously ill some people with Covid were, a failure to tell some people to seek urgent help, and a lack of capacity to deal with a sudden spike in calls. It also raised concerns that the government’s advice to citizens to “stay at home” to protect NHS services deterred people who needed immediate medical attention from seeking it from GPs and hospitals, sometimes with fatal consequences. Mistakes identified by HSIB included that: The CRS algorithm did not allow for the assessment of any life-threatening illness a caller had – such as obesity, cancer or lung disease – to establish whether they should undergo a clinical assessment. When many callers reached the core 111 service, there was no way to divert them as intended to the CRS, which was operationally independent of 111. Although patients who had Covid-19 symptoms as well as underlying health conditions, such as diabetes, were meant to be assessed when they spoke to the core 111 service, some were not. The number of extra calls to 111 in March 2020 meant that only half were answered. Read full story Source: The Guardian, 29 September 2022 -
News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, won a high court battle in December to hear details of an informal chat outside the building between Laura Elliot, a community mental health nurse who was supporting Mays, and the consultant psychiatrist Dr Kwame Fofie, which only later came to light. This was ruled to be “neither a clinical conversation nor an attempt to escalate her care” by senior coroner Prof Paul Marks on Wednesday. He said: “It was a conversation between colleagues in which the frustrations of the working day were vented.” But, he said: “The trust has not covered itself in glory with regard to its dealings with the family and the disclosing of documents.” The Mays have spent the last seven years fighting to hear details of the car park conversation, which could have changed their understanding of what happened before their daughter died. Angela Mays added: “I never considered myself to be a campaigner. I have only considered myself to be a mother who actually wants the truth about the facts relating to her daughter’s death.” Read full story Source: The Guardian, 28 September 2022 -
News Article
Dying patient should have been seen in person
Patient Safety Learning posted a news article in News
NHS officials ruled a man who died after his ear infection was not picked up in GP telephone consultations should have been seen face to face, a BBC Newsnight investigation has found. David Nash, 26, had four remote consultations over three weeks during Covid restrictions but was never offered an in-person appointment. His infection led to a fatal abscess on his brainstem. David first spoke to the practice on 14 October 2020, after finding lumps on his neck. He sent a photograph but was never examined. With David worried the lumps might be cancerous, the GP asked a series of questions about his health and reassured him that while she could not rule it out completely, she was not worried about cancer. She suggested he booked a blood test for two to three weeks' time. In those three weeks, David would go on to speak to another GP and two advanced nurse practitioners but never face to face or via video call. He was actually due to be seen in person at the GP surgery that day, for the blood tests booked some 19 days earlier, when he had presented with neck lumps. But - fearing he could have coronavirus, despite a negative PCR test - the nurse cancelled the bloods and asked David to retest for Covid. In its investigation, NHS England found "the overarching benefit [of this decision] was less than the risk with going ahead with blood tests". After five calls to NHS 111, David was taken to hospital in an ambulance that day but died two days later. NHS England, in a finding seen by Newsnight, said: "A face-to-face assessment should have been offered or organised to confirm the diagnosis and initiate definitive management." Read full story Source: BBC News, 29 September 2022 -
News ArticleFamilies have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'. Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public." But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit." Read full story Source: The Manchester News, 13 September 2022
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News Article
Hospital rated ‘inadequate’ after death prompts inspection
Patient Safety Learning posted a news article in News
A private hospital has been rated ‘inadequate’ by a health watchdog following an inspection prompted by a young patient’s preventable death. Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May. The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020. Mr Caseby had been detained under the Mental Health Act but managed to escape Woodbourne and died after being struck by a train. Earlier this year, an inquest concluded his death was contributed to by neglect on behalf of the hospital. In April, Birmingham and Solihull coroner Louise Hunt flagged urgent concerns about record keeping, risk assessments and security of courtyard fences with Priory Group and the Department of Health and Social Care. Read full story (paywalled) Source: HSJ, 22 September 2022 -
News Article
Many English maternity units not meeting safety standards
Patient Safety Learning posted a news article in News
More than half of maternity units in England fail consistently to meet safety standards, BBC analysis of official statistics shows. Health regulator the Care Quality Commission (CQC) rates 7% of units as posing a high risk of avoidable harm. A further 48% require improvement. The figures are slightly worse than a few years ago, despite several attempts to transform maternity care. The regulator says the pace of improvement has been disappointing. In most cases, pregnancy and birth are a positive and safe experience for women and their families, says the CQC. But when things do go wrong, it is important to understand what happened and whether the outcome could have been different. Laura Ellis lost her newborn son when he was unexpectedly breech during advanced labour. She checked out the CQC rating of her local hospital, Frimley Park, when she was pregnant. Maternity services were good. But Laura didn't realise the unit had been told that it required improvement on safety. Laura said: "It was just so hard. So hard to deal with. So hard to leave as well. How would you leave your baby in hospital when you should be taking them home?" Frimley Park NHS Foundation Trust says it has made a number of changes since Theo died, including an emergency response if a baby is unexpectedly breech during advanced labour. Read full story Source: BBC News, 21 September 2022 -
News Article
Infected blood transfusions killed 1,820 in UK, study estimates
Patient Safety Learning posted a news article in News
An estimated 1,820 people died in the UK after being given contaminated blood transfusions between 1970 and 1991, a report has found. The findings were published by the public inquiry into the scandal. The long period between infection and symptoms appearing makes it difficult to know how many people were infected through a transfusion in the 1970s and 1980s, before it became possible to screen blood donations for the virus. New modelling for the public inquiry estimated that between 21,300 and 38,800 people were infected after being given a transfusion between 1970 and 1991, with a central estimate of 26,800. The study, by a group of 10 academics commissioned by the public inquiry, calculated that 1,820 of those died as a result, although the number could be as high as 3,320. Its findings were based on the rate of hepatitis C infection in the population, the number of blood donations made over that time, the survival rate of the disease and other factors. It found at least 79 and possibly up to 100 people also contracted HIV through donated blood, based on data provided by the UK Health Security Agency (UKHSA), with most infections between 1985 and 1987. It said 67 people in that group had now died, although there was no data confirming the causes of death. The public inquiry into the infected blood scandal began taking evidence in 2019 and is expected to publish its final report in 2023. Read full story Source: BBC News, 17 September 2022 -
Content ArticleThere has been a steady increase in the numbers of people dying at home in recent years. These trends became entrenched during the pandemic, which could reflect people fearful of Covid-19 in hospitals and care homes just as much as broader patient preferences for dying at home. So did those dying at home receive the care they needed, at a good standard? This new research from the Nuffield Trust sheds light on the services used by people who died at home in England, before and during the first year of the pandemic.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans. ‘Clinical investigation booking systems’ are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems. This investigation examines the safety implications of patient communications, produced by booking systems, that do not account for the needs of the patient. In addition, it looks at why patients are ‘lost to follow-up’ after an appointment is cancelled, rescheduled or not attended. Lost to follow-up is the term used to describe a patient who does not return for planned appointments (whether for continued care or evaluations) or is no longer being tracked in the healthcare system when they should be.
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Content ArticleHindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.
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Content ArticleMeasures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognise or respond to deterioration. The current study from Albutt et al. explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalised deteriorating patients. The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
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Content ArticleOn 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
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Content ArticleIn the UK, maternal mortality for Black women is currently almost four times higher than for White women, and significant disparities also exist for women of Asian and mixed ethnicity. In this report the Women’s and Equalities Select Committee reviews what is currently understood about the reasons for disparities in maternal deaths, analyses Government and NHS action to date and existing recommendations for change and consider the ongoing challenges to addressing disparities.
