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Showing results for tags 'Patient death'.
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Content Article
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. -
Content Article
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. -
Content Article
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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Content Article
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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Content Article
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.
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Content ArticleCQC review of ‘do not attempt cardiopulmonary resuscitation’ decisions during the coronavirus (COVID-19) pandemic.
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Content Article
Prevention of Future Deaths report – Averil Hart
Patient Safety Learning posted an article in Coroner reports
Averil Hart died from anorexia nervosa at Addenbrookes Hospital, Cambridgeshire, 6 days short of her 20th birthday. In this report, Sean Horstead, Assistant Coroner, concluded that Averil's death was avoidable and that it was contributed to by neglect. -
Content ArticleIn my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
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Content ArticleThe Coroners and Justice Act allows coroners in England or Wales to issue reports after inquest, if they believe that action should be taken to prevent a future death. Coroners are under a statutory duty to issue a Prevention of Future Death (PFD) report to persons or organisations that they believe have the power to act. Cumulatively, these reports may contain useful intelligence for patient safety.
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Content Article
This joint letter calls on Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, to urgently fund a confidential enquiry into the deaths of Asian and Asian British babies. It is signed by the Chief Executives of Sands, The Royal College of Midwives, NCT and the President of the Royal College of Obstetricians and Gynaecologists. -
Content Article
This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively. -
Content Article
Prevention of Future Deaths report – Ann Geraghty
Patient Safety Learning posted an article in Coroner reports
Ann Geraghty was being treated for heart failure at Good Hope Hospital and subsequently died following a cardiac arrest. In their report, the Coroner raised patient safety concerns relating to two periods of ventricular standstill (this is a rare issue when the heart stops beating and stands perfectly still), which were missed due to a combination of policy, staffing, workplace and equipment issues. -
Content ArticleIn this article in the Pharmaceutical Journal, Carolyn Wickware asks if liquid morphine should be reclassified. She cites research that Oramorph or oral morphine sulphate solution was directly linked to the cause of death in 13 reports since 2013.
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Content ArticleThis guide, developed by the charity Action Against Medical Accidents (AvMA), aims to provide support for people seeking legal advice about a possible clinical negligence claim. It is intended to provide information about what to expect from a first meeting with a lawyer and how to prepare for this.
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Content ArticleThis episode of HSJ’s Health Check podcast considers concerns raised in Coroners Prevention of Future Deaths reports about the impact of pandemic hospital visiting restrictions on patient care and patient safety.
