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Content ArticleGloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
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Content ArticleThis policy explains how the Structured Judgement Review (SJR) process is implemented within Maidstone and Tunbridge Wells NHS Trust. The policy advises staff on how to undertake a mortality case record review, which documentation to use, in which circumstances an SJR is required and how the new process relates to previous systems and processes. The policy also explains how the process links to revised mortality reporting, escalation of concerns and dissemination of learning. It covers all inpatients and Emergency Department patients who die whilst in the Trust’s care, and patients who die within 30 days of discharge.
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Content ArticleEvidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. The objective of this study was to quantify trends in MMRs (maternal deaths per 100 000 live births) by state for five mutually exclusive racial and ethnic groups using a bayesian extension of the generalised linear model network. The study found that while maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.
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Content Article
In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.- Posted
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Content ArticleOn the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report.
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Content ArticleThe extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study from Karlick et al., conducted at an academic, tertiary care medical centre, used qualitative survey data analysed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorised into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviours (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.
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Content ArticleThere have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
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Content ArticleThis report examines the reporting of patient deaths at the Norfolk and Suffolk Foundation NHS Trust (NSFT) between April 2019 and October 2022. It was undertaken by Grant Thornton on behalf of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney integrated care boards at NSFT’s request.
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Content ArticleThis report highlights the failure to learn from preventable state related deaths in the UK. It focuses on concerns around the implementation of recommendations following inquests, public inquiries, investigations and official reviews, calling for the creation of a new independent public body, a National Oversight Mechanism, to address this. The report was launched as part of the ‘No more deaths’ campaign by Inquest, an independent charity combining specialist support for bereaved people following a state related death with campaigning for justice and change.
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Content ArticleThe King's Fund compared the healthcare systems in different countries by doing three things: Reviewed the research literature and assessed previous attempts to rank and compare health care systems. Interviewed academic experts in international health care policy and experts who had extensive knowledge of the UK, German and Singaporean healthcare systems. Analysed the latest quantitative performance data for the UK health care system and the health systems of 18 higher-income peer countries. They analysed data in three main domains: the context the health system operates in (eg, the health status and behaviours of the population) the resources a health system has (eg, levels of staffing, equipment and health care spending) how well the health care systems uses its resources and what it achieves as a result (eg, measures of efficiency in delivering services, quality of care, financial protection from the costs of ill health, and health care outcomes).
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Content ArticleSickle cell disease is the name for a group of inherited red blood cell disorders that affect haemoglobin, which is a protein in red blood cells that carries oxygen through a person’s body. It mainly affects people from African or Caribbean backgrounds, though it can affect anyone. It affects approximately 15,000 people in the UK. In November 2021, the All-Party Parliamentary Group for Sickle Cell and Thalassaemia published a report detailing the issues that people with sickle cell disease experience in relation to their care. The report made 31 recommendations to organisations across the healthcare system to help address these issues. The Healthcare Safety Investigation Branch (HSIB) launched two investigations (see also: Invasive procedures for people with sickle cell disease) to find out what additional learning or knowledge could be added in this area and to provide further insights into the practical challenges patients with sickle cell disease may face when receiving NHS care. HSIB used a real patient safety incident, referred to as ‘the reference event’, to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload.
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Content ArticleMr Stevenson was a 63-year-old man who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned from his post in May 2022 to enter full retirement. On 6 May 2022 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed ciprofloxacin on the 19 May. He had no previous history of depression or mental health problems. Subsequently on the morning of 30 May 2022, Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. At approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed. The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line. Mr Stevenson was found hanging nearby. Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed that he had passed away. During the inquest the coroner was referred by Mr Stevenson’s treating urologist to published literature relating to ciprofloxacin and quinolone antibiotics and a potential rare link to suicide behaviour in patients; although it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
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Content ArticleThis study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
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Content ArticleOn the 9 October 2021 an investigation was carried out into the death of Ms Sandra Diane Finch, a 44 year old woman who had a history of Type 1 diabetes mellitus. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect. The cause of death was: 1a) Ketoacidosis 1b) Uncontrolled Type 1 Diabetes Mellitus 1c) Insulin depravation.
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Content ArticleIn January 2023, the Health and Social Care Select Committee opened an inquiry into Prevention. An interdisciplinary group of six academics, clinicians, and a coroner from the University of Oxford, the University of Birmingham, and London made a submission to that inquiry. They made their submission to the Prevention inquiry after reading and analysing more than 4,000 PFDs and working with coroners and bereaved families, which has highlighted that more must be done in health and social care to learn lessons from preventable deaths. Their full submission has now been published which included a table summarising 12 of their research studies relating to preventable deaths and providing recommendations. We have extracted the table which highlights several patient safety concerns and system safety recommendations.
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Content ArticleThis policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS.
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Content ArticleIn 2022 the charities Sands and Tommy’s came together to form a Joint Policy Unit. Together they are focussed on achieving policy change that will save more babies’ lives during pregnancy and the neonatal period and on tackling inequalities in loss, so that everyone can benefit from the best possible outcomes. This first report from the Unit brings together a range of evidence to identify the key changes needed to save more babies’ lives and reduce inequalities in pregnancy and baby loss. None of the individual data it contains is new, but it gives decision makers a clear view of where we are now, and where action is required to make progress.
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Content ArticleCoroners inquire into sudden, unexpected, or unnatural deaths. We have previously established 99 cases (100 deaths) in England and Wales in which medicines or part of the medication process or both were mentioned in coroners’ ‘Regulation 28 Reports to Prevent Future Deaths’ (coroners’ reports). Authors of this paper, published in Drug Safety, aimed to see what responses were made by National Health Service (NHS) organisations and others to these 99 coroners’ reports.
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Content ArticleDeaths from opioids have increased in England and Wales, despite recognition of their harms. Coroners’ Prevention of Future Death reports (PFDs) provide important insights that may enable safer use and avert harms, yet these reports involving opioids have not been synthesised. Authors of this commentary, published in the Journal of the Royal Society of Medicine, therefore aimed to identify opioid-related PFDs and explore concerns expressed by coroners to prevent future deaths.
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Content ArticleMedicines cause over 1700 preventable deaths annually in England. Coroners’ Prevention of Future Death reports (PFDs) are produced in response to preventable deaths to facilitate change. The information in PFDs may help reduce medicine-related preventable deaths. Authors of this paper, published in Drug Safety, aimed to identify medicine-related deaths in coroners’ reports and to explore concerns to prevent future deaths.
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Content ArticleIn England and Wales, coroners are required to write Prevention of Future Deaths reports when a death is deemed preventable so that action is taken to avert similar deaths. Since July 2013, Prevention of Future Deaths reports have been openly available via the Courts and Tribunals Judiciary website (https://www.judiciary.uk/prevention-of-future-death-reports/). However, their presentation to date have been insufficient to identify trends and learn lessons. The authors of this paper designed a web scraper to create the Preventable Deaths Tracker. On 22 June 2022, 4001 PFDs were scraped, analysed, and compared to the Office of National Statistics’ preventable mortality statistics. This commentary, published in Medico-Legal Journal, summarises the key findings and offers recommendations to improve the Prevention of Future Deaths system so lessons can be learnt to avert preventable deaths.
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Content Article
Diabetes care: Is it fair enough? (Diabetes UK, 10 May 2023)
Patient Safety Learning posted an article in Diabetes
Missed checks, disrupted care and health inequalities have been revealed in a new report from Diabetes UK looking at the state of diabetes care in England. The report reveals that less than half (47%) of people living with diabetes in England received all eight of their required checks in 2021-22, meaning 1.9 million people did not receive the care they need. It is calling for urgent action to address the routine diabetes care backlog and prevent avoidable deaths of people living with diabetes. -
Content ArticleFailure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%–13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care. To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis identifies and synthesise what is known about the human factors that affect escalation of care.
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News Article
Lassa fever: Patient who died in UK ‘was newborn baby’
Patient Safety Learning posted a news article in News
A patient who died from Lassa fever last week was a newborn baby, according to reports. The UK Health Security Agency (UKHSA) confirmed on Friday that an individual with the Ebola-like disease had died in Bedfordshire, and that two other people were infected. All three cases were linked to recent travel in West Africa. The BBC said the fatality had been an infant at Luton and Dunstable Hospital, quoting an email sent to staff by Cambridge University Hospitals NHS Trust. Hundreds of frontline workers at the hospital, as well as at Addenbrooke’s Hospital in Cambridge, were reportedly told to isolate after being identified as potential contacts. Lassa fever is an acute viral infection endemic in parts of Africa, and the UKHSA has assured the public that the risk of further infections in the UK remains “very low”. Read full story Source: The Independent, 15 February 2022 -
News Article
Virus almost 'wholly responsible' for spike in dementia deaths
Patient Safety Learning posted a news article in News
People with dementia, particularly care home residents early in the pandemic, were “disproportionately” vulnerable to fatal Covid infections, according to a new report. The analysis, commissioned by the Scottish Government, also found that excess deaths involving dementia during 2020 were “almost wholly” attributable to Covid. Of the 2,154 deaths where both dementia and Covid were listed on the death certificate, 95 per cent had Covid as the main underlying cause. This contradicts previous suggestions that a rise in dementia deaths early in the pandemic may have been linked indirectly to the virus as a result of “lockdown distress” or an increased use of potentially harmful sedation in elderly people confused by restrictions. The report also found that 73% (1,577) of those who died with both Covid and dementia mentioned on their death certificates had passed away in care homes. Henry Simmons, chief executive of Alzheimer’s Scotland, said their loved ones had been “torn apart by grief and loss” and that the report “raises many more questions as to why so many people with dementia living in care homes quickly became victims of Covid-19”. Read full story Source: The Herald, 10 February 2022
