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Event
Investigation and learning from deaths in NHS Trusts
Sam posted an event in Community Calendar
The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. This conference will also update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email kate@hc-uk.org.uk Follow the conference on Twitter @HCUK_Clare #CQCDeathsreview hub members receive a 20% discount. Email info@pslhub.org for discount code. -
EventPoor lifestyle choices are leading to a rapid growth in non-communicable diseases, resulting in increased healthcare expenditure, preventable morbidity, and premature deaths. The increasingly sedentary nature of our lifestyles, which can lead to obesity or being overweight, has contributed to growth in the numbers suffering from type 2 diabetes and heart disease. Prevention and effective management of long-term conditions is likely to be more cost effective than treating the illnesses as they occur. This webinar will highlight how behaviour change can reduce the likelihood of becoming obese, becoming type 2 diabetic, or suffering from heart disease. The session will look at recommendations around four key health and wellness pillars; activity, sleep, stress and nutrition and how achieving balance across them can help prevent some non-communicable diseases. It will explore ‘social prescriptions’ and the role they can play to help those at risk of, or suffering from these diseases to actively participate in their own health and care. Additionally, it will consider how remote patient monitoring can help proactively manage these patient populations outside of primary and secondary care environments, reducing the burden on NHS resources. Register
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EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths involving COVID-19 and how mortality investigation should be managed in these cases. The conference, chaired by Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician Wrightington, Wigan and Leigh NHS Foundation Trust, will discuss the role of Medical Examiners in learning from deaths. Download brochure Register
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EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance, and will examine how this will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. A 20% discount is currently available. Quote HCUK20dmh when booking. Register
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EventuntilPeople with learning disabilities are at risk of dying too young, and dying unnecessarily. The Learning Disability Mortality Review (LeDeR) in England has found that too often, those deaths are a result of failings within health and social care provision. Reflecting on this has never been more important – during the pandemic, the inequalities that many people with learning disabilities face have been put into stark focus. Today we focus on the stories of Oliver’s and Richard's deaths, and on what lessons we can all learn from this. Oliver McGowan died in 2016. He was 18 years old. Oliver had mild learning disabilities and autism. A recent independent LeDeR review concluded Oliver’s death was avoidable. Richard Handley died in 2012 at the age of 33, from complications arising from constipation. He had Down syndrome and mental health problems. The inquest into his death concluded that their had been “gross failures” in his care and treatment. Paula McGowan and Sheila Handley share the stories of their sons’ lives, and of the healthcare failings that contributed to their deaths. Oliver’s and Richard’s stories are profoundly important and profoundly moving. Register
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Content Article
Blog - When diabetes devices fail (8 December 2020)
Patient-Safety-Learning posted an article in Diabetes
In this article for US magazine Consumer Reports, Rachel Rabkin Peachman looks at the incidence and impact of malfunctions and design flaws in continuous blood glucose monitors, insulin pumps and other diabetes equipment. She highlights the case of Pamela, a 64-year-old with diabetes who died when her insulin pump unintentionally gave her a massive dose of insulin overnight. The numbers of adverse events and deaths reported to the FDA regarding diabetes devices is far greater than for any other type of medical device—between January 2019 and July 2020, almost 400 deaths and 66,000 injuries in the US were linked to commonly used diabetes devices. Reports are spread across the different device manufacturers and demonstrate the complexities of trying to determine the exact cause of each adverse event. The article also includes information on how people with diabetes can protect themselves from device malfunctions and errors. -
Content ArticleIn March 2017 the National Quality Board issued the guidance on the actions all NHS Trusts should undertake to learn from a review of the care provided to patients who die stating it should be integral to a provider’s clinical governance and quality improvement work. Hertfordshire Partnership University Foundation Trust have developed a policy on Learning from Deaths setting out the work to be undertaken to review care provided to service users who die in the Trust's care.
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Content ArticleThis annual publication presents statistics of deaths reported to Coroners in England and Wales in 2021. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests.
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Content ArticleThis observational study in The Lancet Public Health analysed the effects of outsourcing health services to private, for-profit providers. The authors evaluated the impact of outsourced spending to private providers on treatable mortality rates and the quality of healthcare services in England, following the 2012 Health and Social Care Act. The authors found that: an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% in the following year. changes to for-profit outsourcing since 2014 were associated with an additional 557 treatable deaths across the 173 CCGs in England. They conclude that private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.
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Content ArticleDerek Richford shares Harry's Story from last year's HSJ Patient Safety Congress. Derek is grandfather of Harry Richford who died seven days after an emergency delivery at East Kent Hospitals Trust. Derek is joined by Donna Ockenden, Chair of the Independent review of maternity services at Shrewsbury & Telford Hospital, and Sarah-Jane Marsh, Chair of NHS England's Maternity transformation programme, in the 'Actioning recommendations from the Ockenden report' session at the Congress.
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Content ArticleThe first COVID-19 vaccine outside a clinical trial setting was administered on 8 December 2020. To ensure global vaccine equity, vaccine targets were set by the COVID-19 Vaccines Global Access (COVAX) Facility and WHO. However, due to vaccine shortfalls, these targets were not achieved by the end of 2021. Watson et al. aimed to quantify the global impact of the first year of COVID-19 vaccination programmes. The study found that COVID-19 vaccination has substantially altered the course of the pandemic, saving tens of millions of lives globally. However, inadequate access to vaccines in low-income countries has limited the impact in these settings, reinforcing the need for global vaccine equity and coverage.
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Content ArticleThe Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies. A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors. The study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory. Correct stillbirth cause classification is crucial for families and society; when ‘unexplained’, conditions’ true perinatal mortality contributions are uncounted and preventative strategies cannot be appropriately targeted.
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Content ArticleInvestigation of a complaint against the Belfast Health and Social Care Trust A Trust’s failure to perform an examination of a patient on admission to hospital meant he was not assessed by medical staff against this baseline during his time on the ward.
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Content ArticleBenjamin King lived 5-days before parents, Jamie Thomas King and Tamara Podemski, had to pull him off life support. Benjamin's parents share their experience, the value of sharing their story with the media and what changes have happened in UK hospitals since to ensure this won't happen to any other family. The panel discusses the role of human factors and system design and how it can be embraced to ramp up patient safety improvement. Human factors experts across healthcare and aviation will discuss this issue alongside patient advocates who have lost loved ones where the application of principles and methodologies of human factors engineering may have saved their loved ones lives. Hear from the leadership at Christus Muguerza Hospital Sur in Monterrey, Mexico, about their work to become an HRO Champion.
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Content ArticleMidwives and other healthcare professionals are an integral part of many bereaved parents’ birth story and can play an important role in caring for parents when their baby dies. In this blog, Clare Worgan, Head of Training and Education at the charity Sands, talks about the importance of bereavement care to parents, and how training helps healthcare professionals to better provide this care. She outlines five principles of bereavement care and talks about why Sands is calling for bereavement care training to be provided to all staff who come into contact with bereaved parents.
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Content ArticleThe Office for Health Improvement and Disparities, part of the UK Government Department of Health and Social Care, highlighted an emerging signal of increased non-COVID-19-related deaths in England between July and October, 2021, with a potentially disproportionate higher increase in people with diabetes. Valabhji et al. aimed to substantiate and quantify this apparent excess mortality, and to investigate the association between diabetes routine care delivery and non-COVID-19-related-mortality in people with diabetes before and after the onset of the pandemic. They examined whether completion of eight diabetes care processes in each of the two years before the index mortality year was associated with non-COVID-19-related death. Results of the study show an increased risk of mortality in those who did not receive all eight care processes in one or both of the previous two years. These results provide evidence that the increased rate of non-COVID-19-related mortality in people with diabetes in England observed between 3 July and 15 October 2021 is associated with a reduction in completion of routine diabetes care processes following the pandemic onset in 2020.
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Content ArticleSir David Sloman, Chief Operating Officer NHS England and NHS Improvement, has sent a letter to the families involved in the Nottingham Maternity Inquiry announcing that Donna Ockenden will taking over the Inquiry. A copy of the letter is below and attached.
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Content ArticleAlexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition
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Content Article
Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)
Sam posted an article in Coroner reports
Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October. -
Content ArticleMyla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice. The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs. Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived.
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Content ArticleTeri Price has been on a pretty steep learning curve since her husband Greg’s death. She (like many people) made a lot of assumptions about the healthcare system. She assumed that every possible action to make care safe would be undertaken and that healthcare providers worked in a supportive, collaborative environment where they could focus on their patients. Over the last couple of months, leading up to today, Teri has been reflecting on what has happened in the last ten years and what we have learned.
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Content Article
Falling through the cracks: Greg’s story
Patient Safety Learning posted an article in Patient stories
Falling Through the Cracks: Greg’s Story is a short film on Greg Price’s journey through the healthcare system. The film gives a glimpse of who Greg was and focuses on the events of his healthcare journey that ended in his unexpected and tragic death. In spite of the sadness of Greg’s Story, the message of the film is intended to inspire positive change and improvement in the healthcare system. Greg's family believe the film will resonate with the audience and create a platform for further dialogue. They hope people will feel empowered and challenge the status quo of the current healthcare system so we all end up with better care and outcomes. -
Content ArticleIn Sierra Leone, 34% of pregnancies and 40% of maternal deaths are amongst teenagers and risks are known to be higher for younger teenagers. This qualitative study in Reproductive Health aimed to explore the causes of this high incidence of maternal death for younger teenagers, and to identify possible interventions to improve outcomes. Through focus groups and semi-structured interviews, the authors identified transactional sex - including sex for school fees, sex with teachers for grades and sex for food and clothes - as the main cause of high pregnancy rates for this group. They also identified gendered social norms for sexual behaviour, lack of access to contraception and the fact that abortion is illegal in Sierra Leone as factors meaning that teenage girls are more likely to become pregnant. Key factors affecting vulnerability to death once pregnant included abandonment, delayed care seeking and being cared for by a non-parental adult. Their findings challenge the idea that adolescent girls have the necessary agency to make straightforward choices about their sexual behaviour and contraceptives. They identify a mentoring scheme for the most vulnerable pregnant girls and a locally managed blood donation register as potential interventions to deal with the high rate of maternal death amongst teenage girls.
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Content ArticleSystemic racism in maternity care is an urgent human rights issue. For too long, evidence and narratives about why racial inequities in maternal outcomes persist have focussed on Black and Brown bodies being the problem – ‘defective’, ‘other’, a risk to be managed. Birthrights’ year-long inquiry into racial injustice has heard testimony from women, birthing people, healthcare professionals and lawyers outlining how systemic racism within maternity care – from individual interactions and workforce culture through to curriculums and policies – can have a deep and devastating impact on basic rights in childbirth. This jeopardises Black and Brown women and birthing people’s safety, dignity, choice, autonomy, and equality. The inquiry’s report, Systemic Racism, Not Broken Bodies, uncovers the stories behind the statistics and demonstrates that it is racism, not broken bodies, that is at the root of many inequities in maternity outcomes and experiences.
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Content ArticleSarah Louise Dunn was admitted to the Blackpool Victoria Hospital on 10 April 2020. She was suffering from a Group A Streptococus infection following an early medical abortion on 23 March 2020 which by the time of her admission at hospital had produced sepsis and had progressed to toxic shock. Signs of sepsis were apparent before and on her admission given Sarah’s history and symptoms but Sarah was treated upon admission to hospital as a Covid-19 patient. Prior to admission, Sarah had not been seen by a doctor on either 9 or 10 April despite contacting both her GP surgery and the Out of Hours Service. The surgery pharmacist had not read Sarah’s notes properly and was not aware on 9 April that she had recently had undergone an early medical abortion. Her GP on 1 April had not recorded his face to face consultation with her nor noted the possibility of infection. Sepsis was not recognised or treated by the GP surgery, emergency department or Acute Medical Unit and upon Sarah’s arrival at hospital, the sepsis pathway was not followed. Antibiotics were not given to Sarah until 7.5 hours after her arrival at hospital. Sarah suffered a seizure at 6.30pm on the Acute Medical Unit and was transferred to the Intensive Care Unit. These matters in aggregate impacted on her care and Sarah would not have died had she been admitted to hospital sooner. Sarah died on 11 April 2020 on the Intensive Care Unit at Blackpool Victoria Hospital at 2.15am.
