Search the hub
Showing results for tags 'Patient death'.
Found 1,491 results
-
News Article
NHS maternity scandal: Inquiry into baby deaths now looking at 900 cases
Patient Safety Learning posted a news article in News
The inquiry into Britain's worst maternity scandal is now reviewing 900 cases, a health minister has confirmed. The Ockenden Review, which was set up to examine baby deaths in the Shrewsbury and Telford Hospital Trust, was initially charged with examining 23 cases, but Nadine Dorries, a health minister, confirmed to the Commons that an additional 877 cases are being reviewed. A leaked report in November said a "toxic culture" stretching back 40 years reigned at the hospital trust as babies and mothers suffered avoidable deaths. The review will conclude at the end of the year. Jeremy Hunt, the former health secretary, said it was "deeply shocking" to hear of the new details and asked that the inquiry is "resolved as quickly as possible". Read full story Source: The Telegraph, 16 January 2020 -
News ArticleMedical examiners are doctors who look at every hospital death with a fresh pair of eyes to make an independent judgement about what took place. It is impossible to overestimate the importance of their role, and it is vital that NHS hospitals now get on with appointing them as a matter of urgency, says Jeremy Hunt, former Foreign Secretary, in an article in the Independent newspaper. The big issue is not that bad things happen (sadly in an organisation of 1.4 million people there will inevitably be things that go wrong) but that they take so long to identify and put right. Mid Staffs took four years, Morecambe Bay took nine years and it now looks like the problems at Shrewsbury and Telford could have taken place over 40 years. Anyone who has spoken to brave patient-safety campaigners who lost loved ones because of poor care will know that their motivation is never money, simply the desire to stop other families having to go through what they have suffered. That is why they and other patient groups all campaign for medical examiners – a process through which every death is examined by a second, independent doctor. It was first recommended following the Shipman inquiry but has taken a long time to implement – inevitably for cost reasons. Where they have been introduced, medical examiners have been transformational. The main pilot sites in Sheffield and Gloucester, which scrutinised over 23,000 deaths, found that “medical examiners have triggered investigations that identified problems with post-operative infections faster than other audit procedures, based on surprisingly few cases”. Doctors also felt confident in raising concerns, as they were protected and supported by the independent medical examiner. Remarkably, pilot studies found that 25% of hospital death certificates were inaccurate and 20% of causes of death were wrong. Read full story Source: The Independent, 16 January 2020
-
Content ArticleBMJ Quality & Safety, was to determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.
-
Content ArticleThis guidance from the NHS National Quality Board details how trusts should support and engage families after a loved one’s death in their organisation’s care. It consolidates existing guidance and provides perspectives from family members who have experienced a bereavement within the NHS. This guide includes explanations of healthcare terms and processes, so that following a bereavement, families can use the information it contains.
-
News Article
Coroner raps trust for not realising woman was in ‘imminent danger’
Patient Safety Learning posted a news article in News
A coroner has criticised an ambulance trust after it took nearly four hours to reach a woman who had taken an overdose. Taking the unusual step of publishing a prevention of future deaths report before an inquest had concluded, coroner for Gateshead and South Tyneside Terence Carney said “the real and imminent danger of [the deceased Maureen Wharton’s] admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way”. Ms Wharton called North East Ambulance Service Trust to say she was dying of cancer and had taken prescribed drugs, including an opioid-based medication and sleeping pills. She threatened to take more and later called back, appearing drowsier. North East Ambulance Service graded the 61-year-old’s call as “category three”, which meant she should have received a response within two hours. It took three hours and 45 minutes for the ambulance service to access her flat, by which time she was already dead. Mr Carney pointed out no attempts had been made to identify family or other support for her, or to contact other agencies which could have responded. The inquest into her death is expected to conclude later this year. In a statement, NEAS said it has already made changes to safeguard patients in mental health cases, including implementing greater oversight in its control rooms, improving call transfers to crisis teams, mapping available local mental health services, introducing more staff training, and telling patients in a crisis but not at risk of physical harm about other, more appropriate, services. Read full story (paywalled) Source: HSJ, 14 January 2020 -
Content ArticlePeter Duffy, consultant surgeon writes of his 35 years of experience on the front-line of the NHS. Charting his career pathway from auxiliary nurse and unskilled operating theatre orderly, he takes us through his progress to senior consultant surgeon and head of department. In 2015, and after blowing the whistle on a series of near misses, he reluctantly reported an avoidable death, cover-up and ongoing surgical risk-taking to the Care Quality Commission. Within months he was out of work and unemployed. Via avoidable deaths and errors, cover-ups, misuse of public funds, bullying, abuse and victimisation the author charts out in searing detail his demotion, punishments and exile from both family and NHS and the subsequent brutal legal process that followed his illegal dismissal.
-
News Article
Shante Turay-Thomas: Human error factor in allergy death
Patient Safety Learning posted a news article in News
A teenager with a severe nut allergy died in part because of human error, a coroner has ruled. Shante Turay-Thomas, 18, had a severe reaction to eating a hazelnut. The inquest heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London. Her mother Emma Turay, who said she felt "badly let down" by the NHS, wants an "allergy tsar" to be appointed to help prevent similar deaths. The inquest heard call staff for the NHS's 111 non-emergency number failed to appreciate the teenager's worsening condition was typical of a severe allergic reaction to nuts. A telephone recording of the 111 call, made by her mother, at 23:01 BST on Friday 14 September 2018, revealed how the 18-year-old could be heard in the background struggling to breathe. "My chest hurts, my throat is closing and I feel like I'm going to pass out," she said before asking her mother to check how long the ambulance would be, then adding: "I'm going to die." The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, however it later emerged she had only injected a 300 microgram dose, rather than the 1,000 micrograms needed to stabilise her condition. It also emerged she was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device. The inquest at St Pancras Coroner's Court was told an ambulance that was on its way to the patient had been rerouted because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one. Read full story Source: BBC News, 13 January 2020 -
News Article
Regulator admits multiple failings in investigation of young woman’s death
Patient Safety Learning posted a news article in News
Multiple failings have been found in the Parliamentary Health Service Ombudsman's (PHSO) investigation into the death of a young woman with anorexia. PHSO has admitted to multiple failings in how it handled a three-and-a-half year investigation into the systemic failings by NHS providers in Cambridgeshire and Norfolk which led to the death of Averil Hart in 2012. The findings come as a senior coroner in Cambridgeshire investigates whether there are links between the failures in Averil’s care and that of four other women with an eating disorder who were under the care of the same services. The PHSO’s failings have been revealed in an internal review, published today, which ruled the regulator’s investigation took too long and should’ve been completed in half the time. It also found “insufficient” resource was allocated to the Averil’s investigation, despite staff requesting it, which led to significant delays. Read full story Source: HSJ, 10 January 2020 -
News Article
Death review backlog still growing despite NHSE commitment
Patient Safety Learning posted a news article in News
A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802. The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over. Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals." “Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.” Read full story (paywalled) Source: HSJ, 8 January 2020 -
Content ArticleIn her blog for the Professional Standards Authority, Sarah Seddon talks about her personal experience as a patient going through the fitness to practise process. She outlines her thoughts on the key considerations that she believes regulators should take into account to help 'humanise' the process. "I was known as ‘Woman A’. To me, this embodies the entire impersonal, inhumane world of fitness to practise. I wasn’t a person with needs, thoughts and feelings; I wasn’t a bereaved mum; I wasn’t a professional anymore but simply a piece of evidence."
-
News Article
Myla’s mum left with ‘soul‑destroying sadness’
Patient Safety Learning posted a news article in News
Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020 -
Content Article
Family reference group: INQUEST
Claire Cox posted an article in Patient stories
INQUEST is a charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Their specialist casework includes deaths in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question. What is the Family Reference Group? The INQUEST Family Reference Group is made up of people directly affected by a contentious death (i.e. in detention/custody, where a state body is involved, or where the facts are disputed). It supports and contributes to INQUEST's work from a family perspective. The reference group brings together a range of experiences, taking into consideration race and gender perspectives, types of deaths across custody, immigration detention and mental health care. -
Content ArticleThe Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve. Their role: They register health and adult social care providers. They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings. They use our legal powers to take action where we identify poor care. They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice.
-
Content Article
INQUEST: Skills and support toolkit
Claire Cox posted an article in Prison setting
The INQUEST Skills and Support Toolkit is a resource for families and friends dealing with the aftermath of a death in custody and detention. The skills toolkit has been directed by the thoughts and experiences of INQUEST’s family reference group. The group includes a number of families whose relative has died in police custody or following police contact, prison custody, an immigration removal centre and a psychiatric setting. -
Content Article
BMJ Editorial: Abandon the term "second victim"
Patient Safety Learning posted an article in Second victim
Families of patients who died after medical errors argue that it’s time to abandon the term “second victim” to describe doctors who are involved in a medical error. In an editorial published by The BMJ, Melissa Clarkson at the University of Kentucky and colleagues say that by referring to themselves as victims, “healthcare providers subtly promote the belief that patient harm is random, caused by bad luck, and simply not preventable.” This mindset “is incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers,” they argue. -
Content ArticleThe objective of this paper, published by the BMJ, was to determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England, and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI).
-
News Article
Somerset care home failed to notify health watchdog of deaths
Patient Safety Learning posted a news article in News
A residential care home failed to notify the health watchdog about the deaths of people they were providing a service to, its report has found. Kingdom House, in Norton Fitzwarren, run by Butterfields Home Services, was rated "requires improvement". The home cares for people with conditions such as autism. The Care Quality Commission (CQC) said the registered manager and provider lacked knowledge of regulations and how to meet them. Inspectors found the provider failed to notify the CQC about the deaths of people which occurred in the home, as required by Regulation 16 of the Health and Social Care Act 2008. The report also found people were at "increased risk" because the provider had not ensured staff had the qualifications, competence, skills and experience to provide people with safe care and treatment. Inspectors did, however, praise the "positive culture" at the home, that is "person-centred", and noted the provider was "passionate about their service and the people they cared for". Read full story Source: BBC News, 2 January 2020 -
Content ArticleOn 10 May 2017, the RCP (Royal College of Physicians) hosted ‘Learning from mortality reviews to improve patient safety’ as part of it's Keeping patients safe seminar series. The event discussed how the National Mortality Case Record Review (NMCRR) can improve care and keep patients safe. As well as hearing from the RCP's National Mortality Case Record Review (NMCRR) team about their work and the results of the programme's pilot phase, the seminar was an opportunity to hear about the wide-ranging work the RCP is undertaking to support improvements in patient safety.
-
Content ArticleThe Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level across the NHS in England using a standard and transparent methodology. It is produced and published monthly as a National Statistic by NHS Digital. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
-
Content ArticleHealthcare provision in the NHS is very safe but on rare occasions when things go wrong, it is important that those involved are properly informed and supported, compensation is paid fairly, unnecessary costs are contained and that we learn in order to improve. Negligence also comes at significant personal and financial cost for the NHS, not all of which is visible. NHS Resolution has conducted a thematic review into learning from suicide related claims with in the NHS.
-
Content ArticleINQUEST's evidence-based report Stolen lives and missed opportunities: the deaths of young adults and children in prison, documents the deaths of 65 young people and children in prison between 2011 and 2014. In the four years covered, INQUEST reveals an average of more than one young death each month.
-
Content ArticleIn May 2018, INQUEST published Still dying on the inside: examining deaths in women’s prisons providing unique insight into deaths in women’s prisons. The report was based on an examination of official data, INQUEST’s research, casework and an analysis of coroners’ reports and jury findings. This 2019 briefing provides an update to that report, reflecting on the cases and figures for 2018/2019.
-
Content ArticleSam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived. Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
-
Content ArticleHelen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
-
News Article
Woman dies after being set on fire during surgery in Romania
Patient Safety Learning posted a news article in News
A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system. The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant. Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said. A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December. “The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said. Read full story Source: The Guardian, 30 December 2019 the hub has a number of posts on preventing surgical fires: Surgical fires: nightmarish “never events” persist MHRA. Paraffin-based skin emollients on dressings or clothing: fire risk (18 April 2016) National Patient Safety Agency: Fire hazard with paraffin-based skin products (Nov 2007) How I raised awareness of fires in the operating theatre
