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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.
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Content ArticleThe national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
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Content ArticleThis is the first in a series of thematic reports which will be published by the Independent Maternity Services Oversight Panel in the coming year. The purpose of the report is to summarise the learning which is emerging from the ongoing programme of independent clinical reviews of the maternity and neonatal care previously provided by the former Cwm Taf University Health Board. This particular report summarises the key themes and issues which emerged from the clinical review of 28 individual episodes of care1 which were provided by the Health Board between 01 January 2016 and 30 September 20182. It focuses on the care of mothers who needed unplanned emergency treatment during childbirth, including some who required admission to an Intensive Care Unit.
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This is the second in a series of thematic reports to be published by the Independent Maternity Services Oversight Panel about their ongoing programme of independent clinical reviews of the maternity and neonatal care provided by the former Cwm Taf University Health Board. This report focuses on the care of mothers and their babies who were stillborn. It summarises the key themes and issues which emerged from the clinical review of 63 individual episodes of care which were provided by the Health Board between 01 January 2016 and 30 September 2018. -
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Prevention of Future Deaths report – Mary Land
Mark Hughes posted an article in Coroner reports
Mary Land was a patient on an Acute Respiratory care unit 'surge' ward at Pinderfield Hospital, being treated for COVID pneumonia against a backdrop of comorbidities. On 5 February 2021 she was discovered in an unresponsive condition, with the tube connecting her facemask to a BIPAP ventilator detached at the connection point to the mask. In his report, the Coroner raised patient safety concerns relating to how the tubes of her Philips Respironics AF 541 mask became detached from the ventilator. -
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House of Commons Debate - Baby Loss Awareness Week (23 September 2021)
Mark Hughes posted an article in Maternity
This is the transcript of a debate in the House of Commons ahead of Baby Loss Awareness Week (9 to 15 October 2021). In this debate, MPs reflected on personal experiences and those of their constituents, the role of Baby Loss Awareness Week as an essential focal point for bereaved families and the potential for the Government to mandate and fund the National Bereavement Care Pathway programme. -
Content ArticleOn 24 March 2021, an investigation into the death of Hazel Fleur Wiltshire was opened. The conclusion of the inquest was that Mrs Wiltshire died from pneumonia caused by a fall and by COVID-19 that she acquired in hospital. The fall was caused by her trying to relieve herself without assistance in the context of long delays in answering calls bells at the time.
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Content ArticlePrisons and Probation Ombudsman Sue McAllister has published the independent investigation into the death of a baby (Baby A) at HMP Bronzefield on 27 September 2019. The investigation identified a considerable number of issues and concerns about the care and management of Ms A, the baby’s mother. Sue makes a significant number of recommendations to improve maternity services in Bronzefield. There is wider learning for the whole of the women’s prison estate from the death of Baby A, and the Prison Service must take this opportunity to improve the outcomes for pregnant prisoners so that this tragic event is not repeated.
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In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships. -
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Prevention of future deaths report – Paul Sartori
PatientSafetyLearning Team posted an article in Coroner reports
Paul Satori died as a result of a dissecting aortic aneurysm following a misdiagnosis, and being discharged from hospital. -
Content ArticleThe Patient Safety Movement Foundation has compiled all of their achievements over the past year into their first-ever annual report. Despite the global COVID-19 pandemic, they have stayed loyal to their vision of achieving ZERO preventable patient harm and death across the globe by 2030.
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National Medical Examiner’s report 2020
PatientSafetyLearning Team posted an article in Other reports and inquiries
The national medical examiner system is being rolled out across England and Wales, initially on a non-statutory basis, and is part of the Death Certification Reform Programme for England and Wales. It also forms part of the NHS Patient Safety Strategy and the NHS Long Term Plan in England. The all-Wales Medical Examiner Service is a critical part of the long-established mortality review programme. Throughout 2020, medical examiner offices have been established at acute trusts in England and at regional hubs in Wales, initially providing scrutiny of non-coronial deaths in acute care. This remit is being expanded in 2021 and 2022 to cover non-coronial deaths that occur in other settings such as the community. A core part of the medical examiner role is to provide bereaved people with clear information about the cause of death, and an opportunity to raise any concerns they may have about the care and treatment provided to the deceased person. Medical examiners also carry out a proportionate review of patient records and discuss causes of death with the doctor completing the Medical Certificate of Cause of 5 | National Medical Examiner’s report 2020 Death (MCCD). They ensure concerns about patient care are identified promptly and referred for further investigation, to improve services and care for all patients. This report describes progress and next steps, building the foundations of a medical examiner system that will facilitate reflection, learning and improvement across the entire health system. -
Content ArticleUse of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’ Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm.
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Content ArticleThese coroner reports relate to two patients, Stephen and Peter, who both died as a result of complications from use of a nasogastric tube. The coroner notes concerns that this issue may be more widespread and has therefore highlighted the report to several relevant bodies who she advises to take action.
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Content ArticleThis is the coroners report into the death of Brandon-Robert, who was born on 29 May 2020, and died of E. coli sepsis a week later.
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Content ArticleDr Abdulelah Alhawsawi, is the ex-founding Director General of the Saudi Patient Safety Center, and Ministry of Health Advisor on Patient Safety. In this video, he interviews Rt Hon Jeremy Hunt, Chair of the Health and Social Care Select Committee and former Health Secretary. They discuss safety in healthcare, avoidable deaths and how we can realise the vision of zero harm.
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Prevention of Future Deaths report – Brian Button
Patient Safety Learning posted an article in Coroner reports
Brian Button, 78 years old, was admitted to the Royal Sussex County Hospital following a fall but contracted COVID-19 pneumonitis on the Catherine James ward within the Acute Respiratory Unity. Senior coroner for Brighton and Hove, Veronica Hamilton-Deeley, in the coroner's report, said that the ward contained 13 beds and that these beds were not socially distanced. A patient review confirmed this. The Royal Sussex County Hospital has responded. -
Content ArticleWhile the US healthcare system is considered one of the best in the world, many American’s may not realise the potential risks they face when seeking and receiving healthcare. The most recent figures put the rate of preventable healthcare deaths at around 400,000 each year. To put this in perspective, that is more than Alzheimer’s disease, lung cancer, and breast cancer combined kill each year and means that healthcare is the third leading cause of death in the US. That figure does not even reflect the hundreds of thousands of patients who are harmed during their care but do not die. In this article for The Hill, Jill Steiner Sanko explores how we can address preventable healthcare deaths.
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Content ArticleS. Dorothy Smith instinctively knew that something was wrong with her daughter Katiana, but was dismissed as a hysterical first-time mum who just couldn't cope with normal newborn crying. She wrote a guest post for the Hysterical Women website, which can be accessed via the link below.
