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Found 1,489 results
  1. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
  2. Content Article
    On 3 August 2022 an investigation was carried out into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19 July 2022. The investigation concluded at the end of the inquest on the 17 August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.
  3. News Article
    A police investigation into allegations of cover-up and medical negligence over dozens of deaths at the Royal Sussex county hospital (RSCH) in Brighton has been expanded to include more recent cases, amid internal claims about dangerous surgery. In June the Guardian revealed that Sussex police were investigating the deaths of about 40 patients in the general surgery and neurosurgery departments at the RSCH. The force initially said the investigation, since named Operation Bramber, related to allegations of medical negligence in these departments between 2015 and 2020. It has now extended the scope of the investigation to more recent cases, amid internal allegations that the departments continue to be unsafe and fail to properly review serious incidents. An insider said the police should review what was considered to be an avoidable death after a procedure in July. The source said some of the surgeons remained a danger to the public. “You would not want your family members touched by these people,” they said. They added: “This is not a historic issue, it is ongoing. The same surgeons that were involved in previous problems remain in place.” They cited a woman who lost the power of speech in April after an alleged mistake in surgery to remove a brain tumour led to a stroke, and a man who was left with a brain abscess in May after being operated on despite a heightened risk of infection. Read full story Source: The Guardian, 13 September 2023
  4. News Article
    UK plastic surgeons have released new guidelines to try to make Brazilian Butt Lift (BBL) procedures safer for people who desire a bigger bottom. Some women have died from the operation, which involves sucking out fat from elsewhere - such as the belly - and injecting it into butt cheeks. The British Association of Plastic Surgeons (BAAPS) says the injections should not go very deep to help avoid complications such as dangerous clots. According to the NHS, it has the highest death rate of all cosmetic procedures, and the risk of death from BBL surgery is at least 10 times higher than many other procedures. A major concern is that the injected fat can cause a blockage in a blood vessel in the lungs - called a pulmonary embolism - which can be fatal. This happened to Leah Cambridge, a beautician and mother of three from Leeds. She suffered a massive pulmonary embolism during the operation at a private hospital in Turkey in 2018, a coroner found. BAAPS president Marc Pacifico told the BBC: "Unfortunately we don't know how many people have been going for these risky BBL procedures. We have been recommending against it for a number of years after seeing quite a frightening death rate associated with it. But people have been going abroad to get it done." "Make sure you ask if the surgeon will be using ultrasound for gluteal fat grafting. We are recommending that surgeons should only perform this with real time ultrasound guidance as the only way to ensure the procedure is performed superficially and safely." Read full story Source: BBC News, 10 October 2022
  5. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  6. Content Article
    Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.
  7. News Article
    The mother of Martha Mills, whose preventable death in hospital has led to calls for extra patients' rights, has said she is to meet the health secretary to discuss "Martha's Rule". If introduced, it would give families a statutory right to get a second opinion if they have concerns about care. Merope Mills said patients needed more clarity and to feel empowered. Her daughter, Martha, died two years ago after failures in treating her sepsis at King's College Hospital. She had entered hospital with an injury to her pancreas after falling off her bike. The injury was serious but should never have been fatal. Within days she had died of sepsis. In an interview on Radio 4's Today programme, Mrs Mills said she had raised concerns but doctors told her the extensive bleeding was "a normal side-effect of the infection, that her clotting abilities were slightly off". The King's College Hospital Trust said it remained "deeply sorry that we failed Martha when she needed us most" and her parents should have been listened to. Read full story Source: BBC News, 12 September 2023
  8. Content Article
    On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
  9. News Article
    A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.”
  10. Content Article
    On 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.
  11. News Article
    The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
  12. News Article
    A 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS). Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition. EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare. Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness. Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her. There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said. She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said. Read full story Source: The Independent, 6 September 2023
  13. Content Article
    In this article in the Scotsman, former whistle blower, Iain Kennedy, writes about the culture of fear and blame in Scotland's NHS and how NHS staff must feel free to speak up about problems that affect patient safety.
  14. News Article
    North East London Foundation Trust has been charged with corporate manslaughter – making it only the second NHS provider to be prosecuted for the crime. The Crown Prosecution Service has authorised the Metropolitan Police to bring a charge of corporate manslaughter against the mental health provider in regard to the death of Alice Figueiredo at the trust’s Goodmayes Hospital on 7 July 2015. Goodmayes ward manager Benjamin Aninakwa has also been charged with gross negligence manslaughter, and an offence under the Health and Safety at Work Act. The trust and Mr Aninakwa will appear at Barkingside Magistrates’ Court on Wednesday, 4 October. The prosecution follows a five year investigation by Met detectives. Read full story (paywalled) Source: HSJ, 7 September 2023
  15. News Article
    A police investigation is to be launched into failings that led to dozens of baby deaths and injuries at a hospital trust. The maternity units at Nottingham University Hospitals (NUH) NHS Trust are already being examined in a review by senior midwife Donna Ockenden. The review will become the largest ever carried out in the UK, with about 1,800 families affected. Nottinghamshire Police said its decision to investigate followed discussions with Ms Ockenden. Her team is looking into failings that led to babies dying or being injured at Nottingham City Hospital and the Queen's Medical Centre. Chief Constable Kate Meynell said: "On Wednesday I met with Donna Ockenden to discuss her independent review into maternity cases of potentially significant concern at Nottingham University Hospitals NHS Trust (NUH) and to build up a clearer picture of the work that is taking place. "We want to work alongside the review but also ensure that we do not hinder its progress. "However, I am in a position to say we are preparing to launch a police investigation. "I have appointed the Assistant Chief Constable, Rob Griffin, to oversee the preparations and the subsequent investigation." Read full story Source: BBC News, 7 September 2023
  16. News Article
    A father whose daughter died after travelling to Turkey for weight-loss surgery has urged people to think again before doing the same. Shannon Meenan Browse from Londonderry was 32 when she died in August. The mother-of-four travelled for a gastric sleeve operation 18 months ago but, according to her father, got sick almost straight away. The family were told she died in Altnagelvin Hospital from "malnutrition due to gastric sleeve". A BBC investigation in March found that seven British patients who travelled to Turkey for weight-loss surgery died after operations there, while others returned home with serious health issues. One of the UK's leading bariatric surgeons, Prof David Kerrigan said people are taking a "massive risk" by travelling abroad for weight-loss surgery. In the UK, he said, patients undergo a rigorous preparatory process that includes a psychological assessment and there is "a proper after-care programme". Read full story Source: BBC News, 6 September 2023
  17. News Article
    Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found. Their investigation found issues that were flagged a decade ago are still being warned about now. Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart. The coroner who oversaw both cases, noted a repeated failure in care. After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued. Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed. In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years. Read full story Source: BBC News, 7 September 2023
  18. Content Article
    This digital story produced by Patient Voices, hears from Claudia who reflects on the unexpected death of a baby she helped care for in hospital. Claudia describes her own and her team's emotions as they debriefed and embarked on their serious incident report.
  19. Content Article
    This debate was requested by Barbara Keeley MP of Worsley and Eccles South, following the death of Emily Chesterton, the daughter of her constituents Marion and Brendan Chesterton. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died. The conclusion of the coroner was: “Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”
  20. News Article
    Top boss of NHS complaints in England has told the BBC he wants Martha's rule to be introduced to give patients the power to get an automatic second medical opinion about hospital care, when they think things are going wrong. Rob Behrens said he had been moved by the plea of Merope Mills, who shared the story of her daughter's death. Martha was 13 when she died from sepsis. Merope Mills wants hospitals around the country to bring in Martha's rule, which would give parents, carers and patients the right to call for an urgent second clinical opinion from other experts at the same hospital, if they have concerns about their current care. It is something that Parliamentary and Health Service Ombudsman Rob Behrens fully supports. He told BBC Radio 4's Today programme: "Along with many others, I was moved and in great admiration for what Merope has said and done and I give unambiguous support. "Unfortunately, as tragic as this case is, it's not the first and there have been many cases where patients have been failed by their doctors because they haven't been listened to." Read full story Source: BBC News, 5 September 2023
  21. Content Article
    This is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
  22. Content Article
    Martha Mills died from sepsis aged 13 after sustaining a pancreatic injury from a bike accident. The inquest into her death heard that she would likely have survived had consultants made a decision to move her to intensive care sooner. Her mother, Merope, has spoken about the failures in Martha’s care, and how she trusted the clinicians against her own instincts – they didn’t listen to her concerns and instead “managed” her. This report is a response to that call from Martha Mills’ parents to rebalance the power between patients and medics with one purpose only: to improve patient safety. It comes amidst significant evidence that shows that failing to properly listen to patients and their families contributes to safety problems in the NHS.
  23. News Article
    Tonjanic Hill was overjoyed in 2017 when she learned she was 14 weeks pregnant. Despite a history of uterine fibroids, she never lost faith that she would someday have a child. But, just five weeks after confirming her pregnancy she seemed unable to stop urinating. She didn’t realize her amniotic fluid was leaking. Then came the excruciating pain. “I ended up going to the emergency room,” said Hill, now 35. “That’s where I had the most traumatic, horrible experience ever.” An ultrasound showed she had lost 90% of her amniotic fluid. Yet, over the angry protestations of her nurse, Hill said, the attending doctor insisted Hill be discharged and see her own OB-GYN the next day. The doctor brushed off her concerns, she said. The next morning, her OB-GYN’s office rushed her back to the hospital. But she lost her baby. Black women are less likely than women from other racial groups to carry a pregnancy to term — and in Harris County, where Houston is located, when they do, their infants are about twice as likely to die before their 1st birthday as those from other racial groups. Black fetal and infant deaths are part of a continuum of systemic failures that contribute to disproportionately high Black maternal mortality rates. “This is a public health crisis as it relates to Black moms and babies that is completely preventable,” said Barbie Robinson, who took over as executive director of Harris County Public Health in March 2021. “When you look at the breakdown demographically — who’s disproportionately impacted by the lack of access — we have a situation where we can expect these horrible outcomes.” Read full story Source: KFF Health News, 24 August 2023
  24. News Article
    The death of a retired police officer who got his head trapped in a hospital bed was an avoidable accident, an inquest has concluded. Max Dingle, 83, of Newtown, Powys, died after he became stuck between the rails and mattress at the Royal Shrewsbury Hospital on 3 May 2020. The initial post-mortem test gave the cause of death as heart disease. But a second examination, commissioned by Mr Dingle's son, found entrapment and asphyxiation to be the cause. After comparing and discussing their findings, both pathologists then agreed "entrapment did play a significant part in the cause of death", the senior coroner for Shropshire John Ellery said. The inquest was told Mr Dingle's son Phil had asked for the second post-mortem test because "did not accept" the initial findings and had sought the opinion of a pathologist in Australia, where he lives. Max Dingle, who had been admitted to the hospital with shortness of breath, died 15 minutes after he was found to be trapped, the hearing was told. Concluding the inquest, Mr Ellery said: "Based on all the evidence, the conclusions of this inquest are Mr Dingle's death was an avoidable accident." Read full story Source: BBC News, 1 June 2022
  25. News Article
    A lack of diabetes checks following the first Covid lockdown may have killed more than 3,000 people, a major NHS study suggests. Those with the condition are supposed to undergo regular checks to detect cardiac problems, infections and other changes that could prove deadly. But researchers said a move to remote forms of healthcare delivery and a reduction in routine care meant some of the most crucial physical examinations did not take place during the 12 months following the first lockdown. Experts said the findings showed patients had suffered “absolutely devastating” consequences and were being “pushed to the back of the queue”. The study, led by Prof Jonathan Valabhji, the national clinical director for diabetes and obesity, links the rise in deaths to a fall in care the previous year. It showed that, during 2020/21, just 26.5% of diabetes patients received their full set of checks, compared with 48.1% the year before. Those who got all their checks in 2019-20 but did not receive them the following year had mortality rates 66% higher than those who did not miss out, the study, published in Lancet Diabetes and Endocrinology, found. The study shows that foot checks, which rely on physical appointments, saw the sharpest drop, falling by more than 37%. “The care process with the greatest reduction was the one that requires the most in-person contact – foot surveillance – possibly reflecting issues around social distancing, lockdown measures, and the move to remote forms of healthcare delivery,” the study found. Those in the poorest areas were most likely to miss out. Read full story (paywalled) Source: The Telegraph, 30 May 2022
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