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Showing results for tags 'Patient death'.
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Content ArticleRebecca Romero was 15 years old and had a long history of self-harm and mental health problems. On 19 July 2017 she was found dead at her home, with a ligature around her neck. Rebecca had left Pebble Lodge psychiatric unit for a period of leave on 6 July 2017, but never returned to the unit after her leave. The original plan was to transfer her to an alternative unit, Riverside, but as there were no inpatient or day patient places available, a discharge meeting was held on 14 July where a community care package was put in place. She was under the community team at the time of her death, but had not been seen since her discharge.
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Content Article15 year-old Mary Bush had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, and on 6 August 2020, Mary took her own life. In her report, the Coroner raises a number of concerns and highlights action that needs to be taken to prevent future deaths.
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Content ArticleMatthews et al. investigated inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk. They found that stillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.
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Content Article
Learning from Coroner's reports
Patient Safety Learning posted an article in Coroner reports
When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.- Posted
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Prevention of Future Deaths report – Van Tuyen (22 February 2022)
Mark Hughes posted an article in Coroner reports
Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.- Posted
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Prevention of Future Deaths report – Chloe Lumb (17 February 2022)
Mark Hughes posted an article in Coroner reports
Chloe Lumb was known to have a genetic risk of aortic dissection that was being monitored. When she presented to James Cook University Hospital in Middlesbrough on 4 January 2021 a diagnosis of aortic dissection was not made, despite the prior knowledge about her risk and her clinical symptoms. The next day she contacted the hospital following discharge because of ongoing symptoms but was not asked to return to hospital. In her report, the Coroner states that a diagnosis of aortic dissection and appropriate surgical treatment would have prevented Ms Lumb’s death. -
Content ArticleThis report details an independent investigation into a homicide committed by an individual receiving treatment for mental health issues. It identifies lessons that can be learned from this incident and areas where improvements to services could help prevent similar incidents occurring.
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Content ArticleCoroner regulations: Regulation 28 - Report on action to prevent other deaths. Regulation 29 - Response to a report on action to prevent other deaths.
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Content ArticleRule 43 reports were replaced on implementation of the Coroners and Justice Act 2009 with Reports on Action to Prevent Future Deaths (‘reports’) .For short they can be referred to as PFDs or PFD reports or Regulation 28 reports. These reports are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: ‘His death was tragic and terrible, but at least it shouldn’t happen to somebody else.’ Broadly speaking reports should be intended to improve public health, welfare and safety. They should not be unduly general in their content; sweeping generalisations should be avoided. They should be clear, brief, focused
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Content ArticlePresentation from Patricia Harding, Senior Coroner, Mid Kent & Medway, North East Kent, Central & South East Kent on the role of the coroner. Includes reportable deaths, the Cor0navirus Act 2020, how to complete a MCCD, inquests, preparation of reports and giving evidence.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old.
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Content ArticleThis article details the case and findings of an investigation by the Parliamentary and Health Service Ombudsman (PHSO) into the death of Stephen Durkin. Stephen died after suffering organ failure from sepsis, while under the care of Wye Valley NHS Trust. His wife, Michelle Durkin, subsequently made a complaint that delays in the diagnosis and treatment of sepsis led to her husband’s death.
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Content ArticleThe aim of this study from Liu et al. was to assess the impact of the Fetal Medicine Foundation (FMF) first trimester screening algorithm for pre-eclampsia on health disparities in perinatal death among minority ethnic groups.
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Content ArticleOn 8 April 2020 the coroner commenced an investigation into the death of Daniel France, age 17. Danny was 17 years old and was living at a YMCA hostel. He was on medication for depression and had been referred to secondary mental health services. He had made previous suicide attempts. On 3 April 2020 he took his own life. The medical cause of death was asphyxiation by hanging and the conclusion was suicide. Danny was a vulnerable teenager: he had left home and was living in hostel accommodation; he had changed his GP practice; he was trans, had changed his name and had been referred to the Gender Identity Clinic; he had recently been discharged from secondary mental health services in Suffolk and had been referred to mental health services in Cambridge; he had previously been under CAMHS and was now being referred to adult mental health services; he had diagnoses of anxiety and depression and had been prescribed medication; he had made previous suicide attempts and had long term suicidal thoughts He had been assessed by First Response Service but had been considered as not requiring urgent intervention. Safeguarding referrals about Danny were made to Cambridgeshire County Council in October 2019 and January 2020. Both referrals were closed and it was accepted that the decision to close both referrals was incorrect. In December 2019 Danny’s new GP referred him to Cambridgeshire & Peterborough NHS Foundation Trust (CPFT). He had been seen by the Primary Care Mental Health Services but was still awaiting assessment by the Adult Locality Team at the time of his death.
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Content ArticleThis report presents maternal mortality rates in the USA for 2020 based on data from the National Vital Statistics System. Maternal mortality rates, which are the number of maternal deaths per 100,000 live births, are shown in this report by age group and race and Hispanic origin. In 2020, 861 women were identified as having died of maternal causes in the United States, compared with 754 in 2019. The maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births compared with a rate of 20.1 in 2019. In 2020, the maternal mortality rate for non-Hispanic Black women was 55.3 deaths per 100,000 live births, 2.9 times the rate for non-Hispanic White women (19.1). Rates for non-Hispanic Black women were significantly higher than rates for non-Hispanic White and Hispanic women. The increases from 2019 to 2020 for non-Hispanic Black and Hispanic women were significant. The observed increase from 2019 to 2020 for non-Hispanic White women was not significant.
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Content ArticleThis report, the eighth MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2017 and 2019 in the UK. In addition, it also includes Confidential Enquiries into the care of women who died between 2017 and 2019 in the UK and Ireland from mental health-related causes, venous thromboembolism, homicide and malignancy. The report also includes a Morbidity Confidential Enquiry into the care of women who gave birth aged over 45 years. This report can be read as a single document; each chapter is also designed to be read as a standalone report as, although the whole report is relevant to maternity staff, service providers and policy-makers, there are specific clinicians and service providers for whom only single chapters are pertinent. There are seven different chapters which may be read independently, the topics covered are: 1. Surveillance of maternal deaths 2. Older maternal age (morbidity enquiry) 3. Mental health and multiple adversity 4. Malignancy 5. Venous thromboembolism.
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Content Article
Global Drug Policy Index
Steve Turner posted an article in Data and insight
The Global Drug Policy Index provides a score and ranking for each country to show how much their drug policies and their implementation align with the UN principles of human rights, health and development. It offers an important accountability and evaluation mechanism in the field of drug policy. -
Content Article
Prevention of Future Deaths report – Hannah Royle (4 October 2021)
Mark Hughes posted an article in Coroner reports
Hannah Royle was a sixteen-year-old girl on the autism spectrum. Her parents had contacted the NHS 111 service on 20 June 2020 after she became unwell with vomiting and diarrhoea, but they were not advised to go to hospital. Three hours later as her conditioned worsened they phoned again, and the call handler, who took advice from a clinical adviser, opted not to call an ambulance and instead told her parents to make their own way to hospital. She died following a cardiac arrest as she was driven to hospital by her parents. In her findings the Coroner states that the NHS 111 service failed to provide the appropriate triage for Hannah on the information provided to them by her parents. This resulted in a cardio-respiratory arrest arising from an avoidable delay in being adequately resuscitated either by prompt attendance of the emergency services or through earlier admission into hospital. -
Content ArticlePoppy Harris was born at Milton Keynes University hospital on 23 November 2020. Following a protracted labour, she was delivered using Kielland's forceps. She was transferred to John Radcliffe Hospital in Oxford where it was discovered that she had suffered a spinal cord injury and despite all efforts and care she died on 24 March 2021.
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Content ArticleThis narrative review in BMJ Quality & Safety argues that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error and to initiate quality improvement projects aimed at reducing the risk of error and harm. It highlights three approaches that may help with measuring the incidence of diagnostic error: Using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error Using standardised patients (secret shoppers) to study the rate of error in practice Encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process
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Content ArticleIn this blog for The BMJ Opinion, John Middleton argues that the Government must act now, or be faced with much tougher decisions and less popular choices as the winter kicks in. He describes the increasing rates of Covid-19 in the UK and the need for action to avoid a healthcare crisis this winter, highlighting that the NHS and the BMA have both called for urgent action to protect the NHS. He urges the Government to take a multi-faceted approach and use the 'Swiss Cheese' model to combat the spread of coronavirus, rather than focusing on single measures. Living with the virus involves changes to normal life, but they are a small price to pay to save lives, protect people from the long term effects of Covid and prevent the evolution of new virus strains.
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Content ArticleA new report from two House of Commons committees highlights the UK’s failed pandemic response. Martin McKee, professor of European Public Health, London School of Hygiene & Tropical Medicine, unpicks the findings.
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Content ArticleMBRRACE-UK is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to undertake the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). The aims of the MNI-CORP are to collect, analyse and report national surveillance data and conduct national confidential enquiries in order to stimulate and evaluate improvements in health care for mothers and babies. This report focuses on the surveillance of perinatal deaths from 22+0 weeks gestational age (including late fetal losses, stillbirths, and neonatal deaths) of babies born between 1st January and 31st December 2019.
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Content ArticleThese documents are for bereaved families and aim to explain what happens after a bereavement. They include information about how to comment on the care a loved one received and what happens if a death will be looked into by a coroner.
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Content ArticleThis guidance from the NHS National Quality Board details how trusts should support and engage families after a loved one’s death in their organisation’s care. It consolidates existing guidance and provides perspectives from family members who have experienced a bereavement within the NHS. This guide includes explanations of healthcare terms and processes, so that following a bereavement, families can use the information it contains.
