Search the hub
Showing results for tags 'Patient death'.
-
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.- Posted
-
- Coroner
- Coroner reports
-
(and 2 more)
Tagged with:
-
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.
- Posted
-
- Learning disabilities
- Medication
- (and 13 more)
-
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.
- Posted
-
1
-
- Coroner reports
- Patient death
-
(and 3 more)
Tagged with:
-
Content ArticleThis 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.
- Posted
-
- Investigation
- Maternity
- (and 5 more)
-
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.- Posted
-
- Coroner reports
- Coroner
- (and 3 more)
-
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.
- Posted
-
- Prescribing
- Patient safety incident
- (and 9 more)
-
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.
- Posted
-
- Patient
- Patient death
-
(and 4 more)
Tagged with:
-
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.
- Posted
-
- Patient / family support
- Patient death
- (and 3 more)
-
Content Article
HSIB maternity programme year in review 2020/21 (August 2021)
Mark Hughes posted an article in HSSIB investigations
This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken.- Posted
-
- Investigation
- Maternity
- (and 3 more)
-
Content ArticleIn this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
- Posted
- 1 comment
-
1
-
- Patient death
- Duty of Candour
-
(and 2 more)
Tagged with:
-
Content Article
Prevention of Future Deaths report – Azra Hussain
Mark Hughes posted an article in Coroner reports
Azra Hussain died by suicide while a patient at Mary Seacole House, operated and staffed by Birmingham and Solihull Mental Health Foundation Trust. In their report, the Coroner raised patient safety concerns relating to her family being unable to participate in a multidisciplinary team meeting prior to her death due to Covid-19 visiting restrictions.- Posted
-
- Patient death
- Pandemic
-
(and 2 more)
Tagged with:
-
Content ArticleKishorkumar Patel and Kofi Aning were both treated at the Nightingale Hospital in London in April 2021. In both cases there was a serious incident in which the wrong filter was found to have been used within the breathing systems of their intensive care ventilator.
- Posted
-
- Patient death
- Pandemic
-
(and 2 more)
Tagged with:
-
Content Article
House of Commons Debate - Reducing Baby Loss (20 July 2021)
Mark Hughes posted an article in Maternity
This is the transcript of a backbench debate in the House of Commons focused on the UK Government's National Maternity Ambition to halve the rate of stillbirths, neonatal and maternal deaths and brain injuries that occur during or soon after birth by 2025, and to achieve a 20% reduction in these rates by 2020. -
Content ArticleThis is the report of an inquiry conducted by the Health and Social Care Select Committee in 2020/21 which examined the ongoing safety concerns with maternity services and the action needed to improve safety for mothers and babies. It suggests that improvements to maternity services have been too slow to date and recommends several changes, including increasing in the budget for maternity services and reforming existing to litigation processes.
- Posted
-
- Maternity
- Patient harmed
-
(and 3 more)
Tagged with:
-
Content ArticleThis article describes how the Care Quality Commission has charged The Dudley Group Foundation Trust with the deaths of Kaysie-Jane Robinson (14) and Natalie Billingham (33) who were found to have died as a result of safety failures. The Dudley Group Foundation Trust pleaded guilty to the charges in court on 2 July 2021, however, only the death of Ms Robinson was accepted by the trust as a result of their care failures.
- Posted
-
- Patient death
- Patient safety / risk management leads
- (and 1 more)
-
Content ArticleNeonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths.
- Posted
-
- Infection control
- Baby
- (and 2 more)
-
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 introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units Unlike other review 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 3,693 reviews which were completed between March 2019 and February 2020.
- Posted
-
- Baby
- Patient death
-
(and 2 more)
Tagged with:
-
Content ArticleCommissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, this report is based on data for children who died from 1 April 2019 to 31 March 2020 in England.
- Posted
-
- Patient death
- Children and Young People
-
(and 1 more)
Tagged with:
-
Content Article
Prevention of future deaths reports - Mary Mellor
Patient-Safety-Learning posted an article in Coroner reports
Mary Anne Mellor died from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent inserted four years previously. -
Content ArticleWest Midlands Ambulance Service has highlighted the death of a woman which it says was due to “being delayed on the back of an ambulance”, just two days after it warned that lives were ‘at risk’ from long handovers. Below is the full account from the organisation's board paper.
- Posted
-
- Deterioration
- Ambulance
-
(and 1 more)
Tagged with:
-
Content ArticleThis report, published by the National Child Mortality Database, is based on data for children who died between April 2019 and March 2020 in England, and finds a clear association between the risk of child death and the level of deprivation (for all categories of death except cancer). More specifically, Child Mortality and Social Deprivation states that over a fifth of all child deaths might be avoided if children living in the most deprived areas had the same mortality risk as those living in the least deprived – which translates to over 700 fewer children dying per year in England. The report’s authors are now calling on policy makers and those involved in planning and commissioning public health services as well as health and social care professionals to use the data in this report to develop, implement and monitor the impact of strategies and initiatives to reduce social deprivation and inequalities.
- Posted
-
- Children and Young People
- Health inequalities
- (and 3 more)
-
Content ArticleThis investigation from the Healthcare Safety Investigation Branch, focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
- Posted
-
- Medicine - Respiratory
- Patient death
-
(and 1 more)
Tagged with:
-
Content Article
A series of failures: a relative's story
Patient Safety Learning posted an article in Keeping patients safe
At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do. Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.- Posted
- 3 comments
-
1
-
- Patient safety incident
- Patient death
- (and 10 more)