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Showing results for tags 'Patient death'.
Found 1,491 results
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Content Article
Coroner’s inquests: A guide for learners (Health Education England)
Claire Cox posted an article in Inquests
Being called as a witness at an inquest is an infrequent event. It can however cause much anxiety and uncertainty. This guide is written to give advice to learners on how to prepare for an inquest and what support is available. -
Content ArticleSir Stephen Moss, Patient Safety Learning Trustee, is the former Chairman of Mid Staffordshire Hospitals NHS Trust, following their damming Healthcare Commission report of 2009. In this interview with Patient Safety Learning, Sir Stephen tells us about lessons learnt and what more needs to be achieved to make the NHS one of the safest healthcare systems in the world. View video (15 minutes)
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Content ArticleBetween 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area. During this period this hospital was managed by a Board which succeeded in leading its Trust (the Mid Staffordshire General Hospital NHS Trust) to foundation trust (FT) status. The Board was one which had largely replaced its predecessor because of concerns about the then NHS Trust’s performance. In preparation for its application for FT status, the Trust had been scrutinised by the local Strategic Health Authority (SHA) and the Department of Health (DH). Local scrutiny committees and public involvement groups detected no systemic failings. In the end, the truth was uncovered in part by attention being paid to the true implications of its mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. The report was laid before Parliament in response to a legislative requirement.
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Content ArticleThe lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this Healthcare Safety Investigation Branch (HSIB) investigation. In this event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
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Content ArticleA framework to support ambulance trusts in England to learn from deaths in their care.
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Content ArticleThis Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
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Content ArticleThe findings of an independent investigation established to review the management, delivery and outcomes of care provided by the maternity and neonatal services of the University Hospitals of Morecambe Bay NHS Foundation Trust between January 2004 and June 2013.
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Content ArticleInfographic summarising the key messages from the MBRRACE-UK 2018 report 'Saving Lives, Improving Mothers’ Care'.
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Content ArticleThis is the sixth annual report produced for the Maternal, Newborn and Infant Clinical Outcome Review Programme, run by the MBRRACE-UK collaboration. The authors analysed 2.3 million pregnancies from 2015-2017 in the UK and Ireland. During that three-year period, 209 women in the UK and Ireland died during their pregnancies or up to six weeks afterwards from pregnancy-related causes. This is equivalent to just over 9 women per 100,000. The leading cause of maternal deaths in the UK is still cardiovascular disease, including heart attacks, heart failure and heart rhythm problems, and there has been no reduction in maternal deaths from heart-related causes for more than 15 years. The full report can be found through the link below, or you can read the lay summary here.
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Content Article
Each Baby Counts (RCOG, 2019)
Patient Safety Learning posted an article in Maternity
Each Baby Counts is the Royal College of Obstetricians and Gynaecologists (ROCG's) national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. -
Content ArticleA framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care set out by the National Quality Board in 2017.
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Content ArticleThe Parliamentary Healthcare Service Ombudsman published 'Ignoring the alarms: How NHS eating disorder services are failing patients' in December 2017. The families who brought forward their complaints helped uncover serious issues that required national attention. The failings catalogued in the report highlighted a systemic set of problems in relation to identifying, treating and monitoring eating disorders that require a systemic response. This encompasses raising awareness among clinicians, building greater specialist capability and ensuring adult eating disorder services achieve parity with child and adolescent services. This submission provides an overview of the report’s systemic findings and the responses seen to the systemic recommendations made to date.
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Content ArticleThis pack is for acute, specialist, mental health and community trust boards and specifically trust non-executive directors (NEDs) and non-clinical executive directors. It explains what boards are expected to do in relation to the Learning from Deaths framework.
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Content ArticleBoth national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
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Content ArticleWas a lack of situational awareness a contributing factor in the outcome of this 'routine operation'? In this human factors video, Martin Bromiley, a pilot, explains what happened that day and what measures need to be in place to prevent other similar incidents.
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Content ArticleThis document is the second version of the Saving Babies’ Lives Care Bundle, which has been produced by NHS England to help reduce perinatal mortality across England. The second version of the care bundle brings together five elements of care that are widely recognised as evidence-based and/or best practice: reducing smoking in pregnancy, risk assessment, prevention and surveillance of pregnancies at risk of fetal growth restriction; raising awareness of reduced fetal movement; effective fetal monitoring during labour; reducing preterm birth.
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Content ArticleFourth MBRRACE-UK Perinatal Mortality Surveillance Report providing information on UK perinatal deaths for births from January to December 2016. The report focuses on the surveillance of all late fetal losses (22+0 to 23+6 weeks gestational age), stillbirths and neonatal deaths, with data presented by country, by geographical area, by health care provider and by Local Authority.
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Content Article
WHO Safe Childbirth Checklist (December 2015)
Patient Safety Learning posted an article in WHO
Of the more than 130 million births occurring each year, an estimated 303 000 result in the mother’s death, 2.6 million in stillbirth, and another 2.7 million in a newborn death within the first 28 days of birth. The majority of these deaths occur in low-resource settings and most could be prevented. The World Health Organization (WHO) has produced a safe birth checklist. -
Content ArticleBlack women in the UK are five times more likely to die during pregnancy and after childbirth compared to white women (MBRRACE, 2019). A petition recently called for more research into why this is happening and recommendations to improve healthcare for Black Women as urgent action is needed to address this disparity. The petition exceeded the threshold of 100,000 signatures required in order to be considered for debate in Parliament. The Government issued this written response on 25 June 2020.
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Content ArticleSome of the serious findings of external reviews of NHS services from recent years, previously unpublished, have been released to HSJ. An HSJ investigation has found the NHS has kept secret dozens of external reviews into care failings in local services including: A hospital where surgery may have “shortened life expectancy”. An alleged “cartel” of private patients said to be put on NHS lists. “Very high risk” consultant on-call arrangements. Problems with fetal heart monitoring in a maternity service. Potentially unnecessary operations being carried out. Rows among doctors putting patients at risk. Read their full report below.
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Content Article
Deaths in custody guidance
Claire Cox posted an article in Prison setting
The Crown Prosecution Service (CPS) prosecutes criminal cases that have been investigated by the police and other investigative organisations in England and Wales. The CPS is independent and make their decisions independently of the police and government. -
Content Article
Deaths of BAME people in police custody
Claire Cox posted an article in Prison setting
There have been about 1,500 deaths in police custody since 1990, and about one third of those who died were from black and minority ethnic backgrounds. -
Content Article
COVID deaths – how accurate are the statistics?
Patient Safety Learning posted an article in Blogs
Malcolm Kendrick, an NHS doctor, has seen people die and be listed as a victim of coronavirus without ever being tested for it. In his blog, Malcolm says if we do not diagnose deaths accurately we will never know how many died of COVID-19, or ‘because of’ the lockdown. Accurate statistics are vital for planning for the future. We have to accurately know what happened this time, in order to plan for the next pandemic, which seems almost inevitable as the world grows more crowded. What are the benefits of lockdown, what are the harms? What should we do next time a deadly virus strikes? -
Content Article
Coronavirus: 'I didn't want her dying on her own'
Patient Safety Learning posted an article in Blogs
Siobhan Brammeld is a care worker at Massereene Manor care home in County Antrim and leads the social care team. She has sat with several residents as they passed away having contracted COVID-19. In this interview with BBC News NI she says she was convinced some residents had "died before their time". "I feel as though I am on autopilot - it never leaves my head. Sometimes I worry that I could have done more," she said. "These are sad times, scary times too," she added. Siobhan told BBC News that staff felt not enough was done to prepare them for the pandemic and that workers like her were left to the side. "I feel we were left on our own. We as workers were forgotten about as well as the wee residents," she said. "At the start of all this I just wanted to scream at somebody - could someone please come and help these wee residents? I just didn't want them to die before their time." "I watched what was happening in other countries and you knew it was coming, but there didn't seem to be an awful lot happening to prepare us." -
Content ArticlePatient and family involvement is high on the international quality and safety agenda. This paper, published in the International Journal for Quality in Health Care, considers possible ways of involving families in investigations of fatal adverse events and how their greater participation might improve the quality of investigations. There is limited guidance and research on how to constitute effective involvement. There is a need for co-designing the investigation process, explicitly agreeing the family’s level of involvement, supporting and preparing the family, providing easily accessible user-friendly language and using different methods of involvement (e.g. individual interviews, focus group interviews and questionnaires), depending on the family’s needs.
