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Showing results for tags 'Patient death'.
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News Article
Father-to-be died in hospital 'screaming in pain'
Patient Safety Learning posted a news article in News
The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life. Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December. The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate". The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance." At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset". It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient". The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety". Read full story Source: BBC News, 5 December 2019 -
News ArticleNHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
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News ArticleHow many people die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation. In an effort to assess the scope of the problem, The Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner’s reports and hospital inspection records with information about these deaths. The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California’s mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths. The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness. Read full story Source: Los Angeles Times, 1 December 2019
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Content ArticleReducing the burden of harm and instilling better practice requires both systems thinking and committed local ownership. Comparisons of health systems across the world can help visualise best practice, opportunities for learning and potential for diffusion of innovations. Most importantly, depicting the global state of patient safety showcases exemplar safety systems and facilitates exploration of their characteristics and enablers. This report seeks to stimulate ambitious visions and bold action to significantly reduce harm and improve the lives of millions of patients and their families.
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Content ArticleGrowing evidence indicates that improved nurse staffing in acute hospitals is associated with lower hospital mortality. Current research is limited to studies using hospital level data or without proper adjustment for confounders which makes the translation to practice difficult. In this observational study published in BMC Health Services Research, Haegdorens et al. analysed retrospectively the control group of a stepped wedge randomised controlled trial of 14 medical and 14 surgical wards in seven Belgian hospitals. All patients admitted to these wards during the control period were included in this study. Pregnant patients or children below 17 years of age were excluded. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started. Their results are in accordance with previous research and confirm the association between higher nurse staffing levels and lower patient mortality. Furthermore, they also found that a higher proportion of bachelor’s degree nurses is related to a reduction in patient mortality. They proposed a new method to estimate optimal staffing levels using ward level data.
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News Article
Hundreds of families come forward in Shropshire maternity scandal
Patient Safety Learning posted a news article in News
More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019 -
News Article
GP who downplayed symptoms of boy who died from Addison’s disease is suspended
Patient Safety Learning posted a news article in News
A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months. Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black. But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour. Read full story (paywalled) Source: BMJ, 25 November 2019 -
Content Article
Our son's final days: "It was like he didn't matter"
Patient Safety Learning posted an article in Patient stories
Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. They tell their story to BBC News. -
News ArticleIn March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua. The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale. James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families." Read full story Source: The Independent, 21 November 2019
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News Article
Patient died after 'transplant surgeon error'
Patient Safety Learning posted a news article in News
A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations. The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants. The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales. It had involved a surgeon from Oxford University NHS Foundation Trust. Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients. The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. It was only when people who received the organs became unwell that the truth was told." Read full story Source: BBC News, 21 November 2019 -
Content Article
My experience in a coroner’s court – a nurse perspective
Anonymous posted an article in Florence in the Machine
This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time.- Posted
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Content ArticleHSIB has identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks, risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.
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News Article
Shrewsbury and Telford Hospital: Babies and mums died 'amid toxic culture'
Patient Safety Learning posted a news article in News
Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent. It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it". The trust apologised and said "a lot" had been done to address concerns. In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement. Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage. The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort". Read full story Source: BBC News, 20 November 2019 -
Content ArticleHospital Watchdog is a nonprofit patient advocacy organisation in the US that champions safe hospital care for patients. They are a diverse group that includes nurses, physicians, pharmacists, healthcare experts, attorneys and members of the public. Some of them have experienced or witnessed medical errors that led to an extremely serious or tragic outcome. They are committed to improving unsafe conditions in hospitals. In February 2019, Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville Missouri.
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Content ArticleWhen Julie Bailey took her mother, Bella, into Mid Staffs Hospital in September 2007 she had no idea that her life was about to change forever. Over the next eight weeks she would witness such shocking neglect and abuse of elderly, vulnerable patients that the memories would haunt her for the rest of her life. And over the next five years she would uncover a culture of deceit and denial going right to the top of the NHS. From Ward to Whitehall is the story of Julie s fight for the truth to be uncovered about the deadly failings at Mid Staffs Hospital and her struggle to ensure that the tragedy would never be repeated.
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Content ArticleHarold Shipman was an English doctor who killed approximately 15 patients while working as a junior hospital doctor in the 1970s, and another 235 or so when working subsequently as a general practitioner. Is it possible to learn general lessons to improve patient safety from such extraordinary events? In this paper, published in the US Journal of the Royal Society of Medicine, it is argued that it is not possible fully to understand how Shipman came to be such a successful and prolific serial killer, nor to learn how the safety of healthcare systems can be improved, unless his diabolical activities are studied using approaches developed to investigate patient safety.
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Content Article
Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor. -
Content ArticleThis powerful blog by Sarah Seddon discusses her experience during a 'fitness to practice' hearing. Sarah is a clinical pharmacist, however , has now found herself as a witness following the tragic death of her son Thomas. This blog explains what it is like for the witness during the process and how it made her feel.
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Content ArticleThe Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
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Content ArticleAn independent review into the widespread failings by Liverpool Community Health Trust. The review conducted by Dr Bill Kirkup CBE, commissioned by NHS Improvement, looks into the issues at the Trust from November 2010 to December 2014. It also looks at the oversight of the Trust by the NHS Trust Development Authority, NHS England and commissioners.
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Content ArticleFollowing a reported death, the National Patient Safety Agency (NPSA) commissioned the Health and Safety Executive to undertake fire hazard testing with white soft paraffin on a variety of bandages, dressings and clothing. The results showed the ability to reproduce the fire hazard in a controlled environment. This risk was not previously well recognised.
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Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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Content ArticleA report from the Public Administration Select Committee looking at the investigation process, how it impacts those involved and how risk can be reduced through learning.
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Content ArticleIn our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
