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Showing results for tags 'Patient death'.
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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. -
Content ArticleThis report looks into the circumstances surrounding the deaths of three young adults; Joanna, Jon and Ben. They each had learning disabilities, were patients at Cawston Park Hospital and died within a 27 month period (April 2018 to July 2020). It highlights multiple significant failures in care, including excessive use of restraint and seclusion, overmedication of patients, lack of record keeping and the physical assault of patients. The report also makes a series of recommendations for critical system and strategic change, both at a local and national level.
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Content ArticleMore and more people are dying at home, rather than in a hospital or hospice. With this trend set to continue, how can commissioners ensure that end-of-life care reflects this and meets the needs of people approaching the end of their lives and their loved ones? This new report from the King's Fund explores what we know about commissioning end-of-life care, the inequalities experienced by particular groups, and how NHS and social care commissioners in England are measuring and assuring the quality of care people receive. Drawing on interviews with commissioners, stakeholders and experts in end-of-life care, as well as recently bereaved carers and family members, this report offers reflections and recommendations for those wanting to improve end-of-life care for those dying at home.
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Content Article
MDU: Cautionary tales - Real member stories
Patient Safety Learning posted an article in Legal matters
These case studies, based on MDU members' real-life experiences, provide a valuable opportunity for shared learning across a wide range of specialties and situations. MDU is a UK medical defence organisation. -
Content ArticlePrevention of Future Deaths Reports (PFDs) made by coroners to address concerns arising from inquests can provide powerful leverage for change, although the reality is that health and social care organisations would generally rather avoid a PFD if possible because they also highlight - in a very public way - concerns about how their services operate which can, in turn, lead to further regulatory scrutiny, principally from the CQC. The need for more consistency in terms of thresholds for making PFDs and the form these take, plus the Chief Coroner’s strong commitment to ensuring that PFDs do what they are designed to do - i.e. harness learning from deaths - have been key drivers behind a recent re-vamping of the existing Chief Coroner’s guidance note on this. What do health and social care organisations need to know about the revised PFD guidance? This briefing looks in more detail about what’s changed (and what hasn’t).
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News Article
Three investigations launched into trust beset by bullying and safety scandals
Patient Safety Learning posted a news article in News
Three “major” reviews are being launched into a struggling teaching trust in response to growing concerns over bullying and poor workplace culture. Birmingham and Solihull integrated care board has begun a series of investigations into University Hospitals Birmingham, whose chief executive announced he was standing down last month. The first review will get under way immediately and will focus on specific allegations made recently on BBC Newsnight. These include patient safety concerns, the “bullying” of clinicians and the issues raised by a review of 12 patient deaths undertaken by former consultant Dr Manos Nikolousis in 2017. It will be led by an “experienced senior independent clinician” from outside the local health system who is expected to report by the end of January. The second and third investigations will review the trust’s leadership and broader cultural issues respectively. The probes will be carried out with UHB and NHS England. Both are expected to report in the first half of 2023. Read full story (paywalled) Source: HSJ, 9 December 2022 -
News Article
Parents of man left to die in prison say care failures will haunt them for ever
Patient Safety Learning posted a news article in News
The parents of a 25-year-old man left to die in a cell by a negligent prison nurse given responsibility for 800 inmates have told how the conditions in which their son died will haunt them for ever. The case – the 27th death in just five years at HMP Nottingham – was said to illustrate the desperate state of Britain’s understaffed and increasingly dangerous prison system. Alex Braund was being held on remand awaiting trial when he fell ill in his cell with the first signs of pneumonia on 6 March 2020. Four days later, on the morning of 10 March, after a series of ill-fated attempts by Braund’s cellmate to get prison staff to take the situation seriously, the young man collapsed. Prison staff responded to an emergency bell rung by Braund’s cellmate at 6.55am, but they initially only looked through the cell hatch, taking five minutes to enter the cell in order to give CPR. Braund was subsequently taken to Queen’s medical centre in Nottingham, where he was pronounced dead at 11.44am of cardiac arrest caused by pneumonia. The jury at an inquest at Nottinghamshire coroner’s court found there had been a “continuous failure to provide adequate healthcare”, with a prison officer told by a nurse a few hours before Braund’s death that there was “nothing to be done at this time of night”. Questioning during the hearing revealed that the nurse, who has since lost her job and been reported to the nursing and midwifery council, had amended her records on the morning of Braund’s death. Read full story Source: The Guardian, 6 December 2022 -
News Article
Six children have died with Strep A bacterial infection
Patient Safety Learning posted a news article in News
There have been five recorded deaths within seven days of an invasive Strep A diagnosis in children under 10 in England this season, the UK Health Security Agency has said. A child under the age of 10 has also died in Wales after contracting the infection. Group A strep bacteria can cause many infections, ranging from minor illnesses to deadly diseases, but serious complications and deaths are rare. According to UKHSA data, there were 2.3 cases of invasive disease per 100,000 children aged one to four this year in England, compared with an average of 0.5 in the pre-pandemic seasons (2017 to 2019). There have also been 1.1 cases per 100,000 children aged five to nine, compared with the pre-pandemic average of 0.3 (2017 to 2019). The UKHSA said investigations are under way following reports of an increase in lower respiratory tract Group A Strep infections in children over the past few weeks, which have caused severe illness. It added that there is no evidence to suggest a new strain of Strep A is circulating, and the increase is most likely related to high amounts of circulating bacteria and social mixing. Read full story Source: Sky News, 3 December 2022 -
News Article
Germany faces ‘catastrophic’ paediatric bed shortage as RSV cases soar
Patient Safety Learning posted a news article in News
Intensive care doctors in Germany have warned that hospital paediatric units in the country are stretched to breaking point in part due to rising cases of respiratory infections among infants. The intensive care association DIVI said the seasonal rise in respiratory syncytial virus (RSV) cases and a shortage of nurses was causing a “catastrophic situation” in hospitals. RSV is a common, highly contagious virus that infects nearly all babies and toddlers by the age of two, some of whom can fall seriously ill. Experts say the easing of coronavirus pandemic restrictions means RSV is affecting a larger number of babies and children, whose immune systems aren’t primed to fend it off. Cases of RSV and other respiratory illnesses have also increased in the UK and in the US, which is also suffering from a shortages of antivirals and antibiotics. In Germany, hospital doctors are having to make difficult decisions about which children to assign to limited intensive care beds. In some cases, children with RSV or other serious conditions are getting transferred to hospitals elsewhere in Germany with spare capacity. “If the forecasts are right, then things will get significantly more acute in the coming days and week,” Sebastian Brenner, head of the paediatric intensive care unit at University Hospital Dresden, told German news channel n-tv. “We see this in France, for example, and in Switzerland. If that happens, then there will be bottlenecks when it comes to treatment.” Others warned that, in certain cases, doctors already were unable to provide the urgent care some children need. “The situation is so precarious that we genuinely have to say children are dying because we can’t treat them any more,” Dr. Michael Sasse, head of paediatric intensive care at Hanover’s MHH University hospital, said. Read full story Source: The Guardian, 1 December 2022 -
News ArticleA woman spent “four hours watching her mother dying on the floor waiting for an ambulance in a journey that should take just ten minutes”, the Irish Oireachtas Health Committee was told today. Committee deputy chairman Sean Crowe said the “woman died on her way to hospital”. Her bereaved daughter was left with the memory of her mother “gasping for breath”, he told Health Minister Stephen Donnelly. He said ambulance delays, compounded by them having to wait backed up for hours outside hospitals because of a lack of trolleys in emergency departments, were leading to serious consequences. In response the minister said: “The national ambulance service needs significant additional funding and that is happening now.” He said there is work under way to rebuild ambulance bases as well as add to the fleet, along with hiring more advanced paramedics. He added: “We need to recognise response times from ambulances are not where they need to be and vary around the country. It is not yet where it needs to be and some areas are worse than others.” Read full story Source: Independent Ireland, 30 November 2022
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News ArticleMore than 200 people who died last week in England are estimated to have been affected by problems with urgent and emergency care, according to the president of the Royal College of Emergency Medicine. Dr Adrian Boyle, who is also a consultant in emergency medicine, told BBC Radio 4’s Today programme that a failure to address problems discharging patients to social care was a “massive own goal”. Ambulances had become “wards on wheels” while patients waited to get hospital treatment, Boyle said, adding that those most at risk “are the people that the ambulance can’t go to because it’s stuck outside the emergency department”. His comments came as the NHS launched 42 “winter war rooms” across England, designed to use data to respond to pressures on the health system. When asked about the project, Boyle said it was too early to tell if it was a good idea, adding: “You can paralyse yourself with analysis, it really is actually more simple and about building increased capacity.” He said the problem was best solved by focusing on hospital discharge and social care. “Fixing this starts at the back door of the hospital and being able to use our beds properly,” he said. “At the moment, there are 13,000 people waiting in hospitals, about 10% of the bed base, who are waiting to be discharged either to home, with a little bit more support, or to a care facility. And that’s just a massive own goal. We just need to reform the interface between acute hospitals and social care.” Read full story Source: The Guardian, 1 December 2022
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News ArticleThe NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, after 700 families previously came forward with their concerns. Of these, the number of families expected to be covered by the probe is more than 1,500 – surpassing the 1,486 examined during the UK’s current largest maternity scandal in Shrewsbury. Read full story Source: The Independent, 30 November 2022
