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Showing results for tags 'Patient death'.
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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.
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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. -
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).
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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. -
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.
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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.
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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.
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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 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.
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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.
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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.
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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.
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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.
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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
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Content ArticleThis Prevention of Future Deaths report relates to the death of four patients who all died from endoscopic retrograde cholangio-pancreatography (ERCP) related complications, within a six-month period. All four patients had their treatment carried out by the same doctor during his training for this high-risk procedure. In her report, the Coroner Laurinder Bower raises concerns about the systems in place to gain consent and inform patients of the risks of these procedures.
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Content ArticleMollie Daisy Dimmock died from perinatal asphyxia due to hypoxia 34 minutes after being delivered. This was caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Mollie was fully delivered. In his report, the Coroner Crispin Butler raises concerns about the NICE guidance in relation to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
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Content ArticleBarrie Housby had a medical history that included frailty, Parkinson’s disease and macular degeneration. During a stay at Clifton Hospital he was known to be at high risk of falls and at the beginning of the nightshift on 12 July 2021, it was advised that he should be cared for on a one to one basis and not left unattended. During the shift, a member of staff allocated to monitor him left the bay to attend to other duties, and in this time Mr Housby left his bed and fell. He was transferred to a hospital emergency department but subsequently died on 13 July 2021 as a result of a traumatic subdural haemorrhage following a fall. In his report, the Coroner Alan Wilson highlights the impact of staffing shortages at the Trust and their contribution to Mr Housby’s death, stating that this poses an ongoing risk to patient safety.
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Content ArticleDelays to timely admission from emergency departments (EDs) are known to harm patients. In this study, Jones et al. assessed and quantified the increased risk of death resulting from delays to inpatient admission from EDs, using Hospital Episode Statistics and Office of National Statistics data in England.
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Content ArticlePoster from the Princess Alexandra Hospital on their Learning from deaths project.
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Content ArticleSurekha Shivalkar was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Following surgery she suffered a cardiac arrest and subsequently died. The conclusion of the inquest was that died from multi-organ failure and complications arising during anaesthesia and hip revision surgery, which led to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. In his report, the Coroner raises concerns about the lack of a use of a formal risk assessment tool prior to her surgery, communication failures between the orthopaedic surgical team and the anaesthetist and the departure of the Senior Consultant surgeon prior to the surgeries conclusion.
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Content ArticleThe Royal College of Anaesthetists is launching a campaign to prevent future deaths from unrecognised oesophageal intubation following a recently received coroner’s report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. The coroner’s report highlighted the critical importance of human factors in safe anaesthetic practice. In this blog, Matt Bigwood and Chris Frerk discuss how one of the main aims of the campaign is to empower every team member, regardless of position, to be able to speak up if they spot this problem. You can also read more about the campaign here.
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Content Article'Kicking the Hornet’s Nest' is a documentary that looks at power morcellation, a popular gynaecologic procedure used to perform hysterectomies. The documentary demonstrates how the practice has been inadvertently spreading cancer in patients for decades. It includes first-person testimonies and archival footage and follows two married, Harvard-affiliated whistle-blowers who have been personally impacted by the procedure, as they campaign to expose the controversial practice and prevent future needless deaths.
