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Showing results for tags 'Patient death'.
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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.
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Content ArticleThe number of patients who die from post-surgical complications in low- and middle-income countries is shockingly high. In Africa alone, more than 600,000 people die each year after surgery, mostly from causes that are relatively easy to treat. This blog by Pierre Barker, Chief Scientific Officer at the Institute for Healthcare Improvement (IHI) looks at a method for reducing post-surgical death called the '5Rs for rescue': Risk stratification Recognise deterioration Respond Reassess Reflect/Redesign He describes how the IHI will test how to support the reliable implementation of the '5Rs for Rescue', which aims to reduce mortality by 25%.
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Content ArticleThis blog by Dr Georgia Richards looks at the system of learning from preventable deaths in the UK. She highlights that following the publication of a Prevention of Future Deaths report (PFD), there is no system in place to ensure responses are received and actions are taken. She then describes how the Preventable Deaths Tracker collects information from PFDs to screen and analyse preventable deaths, so that lessons can be learnt
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Content ArticleThis paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.
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Content ArticleWomen should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
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Content ArticleResearchers writing in the Journal of the Royal Society of Medicine say that while UK life expectancy has increased in absolute terms over recent decades, other, similar countries are experiencing larger increases. In 1952, when Queen Elizabeth II came to the throne, the UK had one of the longest life expectancies in the world, ranking seventh globally behind countries such as Norway, Sweden and Denmark. In 2021 the UK was ranked 29th. The researchers show the rankings of the G7 countries at each decade from 1950 to 2020. The G7 is a collection of countries with advanced economies (UK, Canada, France, Germany, Italy, Japan and the U.S.) that represent about half of global economic output.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Isabela shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy. She talks to us about the vital role of patient campaigners in driving the movement to reduce avoidable harm, and why we need to shift from patient inclusion to belonging in order to improve patient safety. -
Content ArticleIn this Channel 4 Dispatches programme, secret footage filmed over the winter reveals ambulance workers battling the odds and A&E departments overwhelmed as patients suffer needless harm and death The footage comes from Daniel Waterhouse, an emergency medical technician who wore a body-mounted camera during his shifts in north-west London for three months this winter, filming every crumbling layer of a system that is close to total destruction.
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Content ArticleStatement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
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Content ArticleDysphagia (swallowing problems) occurs in all care settings and although the true incidence and prevalence are unknown, it is estimated the condition can occur in up to 30% of people aged over 65 years of age. Stroke, neurodegenerative diseases and learning disabilities can be the cause of some cases of dysphagia, and may also result in cognitive or intellectual impairment, as well as visual impairment, NHS England received details of an incident where a care home resident died following the accidental ingestion of the thickening powder that had been left within their reach. Whilst it is important that products remain accessible, all relevant staff need to be aware of potential risks to patient safety. Appropriate storage and administration of thickening powder needs to be embedded within the wider context of protocols, bedside documentation, training programmes and access to expert advice required to safely manage all aspects of the care of individuals with dysphagia. Individualised risk assessment and care planning is required to ensure that vulnerable people are identified and protected.
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Content ArticleIt's now a decade since the Francis Report, which outlined the causes of serious failures in care at Mid Staffordshire NHS Foundation Trust. The report and prior media coverage exposed a wide set of issues surrounding the culture and transparency of health care, and these topics remain of major concern today. In this article for the Nuffield Trust, Shaun Lintern has interviewed Sir Robert Francis KC about the weight of those patient stories and treatment of the NHS's staff, then and now.
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Content ArticleEmergency care services in the UK face an unparalleled crisis, with more patients than ever before experiencing extremely long waiting times in Emergency Departments (EDs), associated with patient harm and excess deaths. This explainer from the Royal College of Emergency Medicine (RCEM) outlines the latest data on ED waiting times and the impact this is having on patient safety.
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Content ArticlePeter Seaby had Down's Syndrome and autism and was cared for at home by members of his family for 62 years. However, in 2017, Peter was removed from the home he shared with his sister Karen, who was his full time carer, and placed in a care home. Karen and Peter's brother Mick were not told by social services why Peter was moved. Within six months of being in the home, Peter choked on a carrot and died. Karen and Mick found the subsequent inquest into Peter's death in July 2021 to be inadequate and launched a Judicial Review challenge which was successful in quashing the findings of the initial inquest. A new inquest was held in February 2023 Journalist George Julian has been following and reporting on Peter's second inquest and has written several blog posts about the case, highlighting serious failings in his care that led to his death: Peter Seaby’s 2nd inquest – how he came to be in the care of the Priory Group Peter Seaby’s 2nd inquest “I have stood on my own in this” Peter Seaby’s 2nd inquest – the SALT plan Peter Seaby’s 2nd inquest – record keeping and decision making Peter Seaby’s 2nd inquest – April 2018 Peter Seaby’s 2nd inquest – May 2018 Peter Seaby’s 2nd Inquest – Conclusion
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Content Article
Every day in 2020, approximately 800 women died from preventable causes related to pregnancy and childbirth - meaning that a woman dies around every two minutes. Sustainable Development Goal (SDG) target 3.1 is to reduce maternal mortality to less than 70 maternal deaths per 100 000 live births by 2030. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2020.
