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Content ArticleDiagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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News Article
Seven more avoidable sepsis deaths spark coroner warnings
Patient Safety Learning posted a news article in News
Preventable deaths of seven people from sepsis – including four children – have prompted coroners to flag major concerns about NHS services’ management of the condition. Since the start of March, six English coroners have sent formal warnings to trusts, NHS England and the government warning of systemic failures to spot sepsis and delays in administering antibiotic treatments. It comes after an HSJ investigation in February uncovered more than 30 avoidable deaths from sepsis, and undertook analysis of internal figures revealing repeated failures by NHS trusts to provide prompt treatment. Coroner warnings since March include: Two notices were sent this week by Nottingham assistant coroner Elizabeth Didcock to Sherwood Forest Hospitals Foundation Trust, raising concerns over its ability to provide safe paediatric care following the deaths of 10-week-old Tommy Gillman and five-year-old Meha Carneiro from sepsis; A warning from earlier in April criticising University Hospitals Birmingham FT for its failure to treat 56-year-old Tracey Farndon’s sepsis and low blood pressure. Read full story (paywalled) Source: HSJ, 17 April 2024 -
Content ArticleThis French cohort study in JAMA Internal Medicine aimed to find out whether spending a night in the emergency department (ED) associated with increased in-hospital mortality and morbidity among older patients. The results showed that older patients who spent a night in the ED showed a higher in-hospital mortality rate and increased risk of adverse events compared with patients admitted to a ward before midnight. This finding was particularly notable among patients with limited autonomy.
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News Article
Concerns at Nottinghamshire hospital after baby's sepsis death
Patient Safety Learning posted a news article in News
The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024 -
Content ArticleTommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.
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News Article
Causes of death to be scrutinised in revamp of death certificates
Patient Safety Learning posted a news article in News
Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified. From September, medical examiners will look at the cause of death in all cases that haven’t been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity. They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died. The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation. Health Minister, Maria Caulfield said: Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way. The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses. From 9 September 2024 it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny. Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for Royal College of Pathologists, said: “As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms. “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.” Read full story Source: Gov.UK, 15 April 2024 -
News Article
Deaths inquiry extended to last three years
Patient-Safety-Learning posted a news article in News
A statutory inquiry into deaths of mental health patients will now cover fatalities that took place as late as December 2023. The inquiry’s investigations are focused “on the trusts which provide NHS mental health inpatient care in Essex”. This includes: “Essex Partnership University Foundation Trust, and the North East London Foundation Trust and their predecessor organisations, where relevant.” NELFT was not specifically mentioned in the original terms of reference although the inquiry told HSJ it had been within the original scope. The inquiry will also now cover deaths of NHS patients from Essex who died when under the care of private sector providers. The inquiry’s previous terms of reference covered a period ending in 2020. However, the inquiry’s chair, Baroness Kate Lampard, proposed extending the inquiry’s scope last year due to “ongoing concerns” over services at EPUFT. Read full story (paywalled) Lampard Inquiry: Terms of reference Source: HSJ, 11 April 2024 -
Content Article
Lampard Inquiry: terms of reference (10 April 2024)
Mark Hughes posted an article in Other reports and inquiries
The Lampard Inquiry will seek to understand the events that led to the tragic deaths of mental health inpatients under the care of NHS trusts in Essex between 2000 and 2023. This document outlines the terms of reference set following consultation with the chair of the inquiry, Baroness Lampard. -
Content ArticleNHS England’s response to claims of excess deaths due to long A&E waits leaves a lot to be desired, writes Steve Black for the HSJ. The Royal College of Emergency Medicine (RCEM) claim that more than 250 A&E patients are dying each week because they waited more than 12 hours to be admitted. If long waits in A&E are killing an extra 250-400 people every week, it is the biggest performance problem in the NHS. NHSE should urgently ask their analysts to rework this analysis with current data to test (or refute) the validity of the claim. The first step to solving a huge problem is admitting the scale of the problem, not denying it exists. This analysis features a refinement of the RCEM estimate that includes estimated mortality from waits between four and 12 hours. This increases the estimate to 400 extra deaths per week compared to the RCEM number of 250.
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Content ArticleIn November 2023, the Parliament’s Justice Select Committee launched a follow-up inquiry to The Coroner Service, to examine changes and progress since the first inquiry in 2020-2021.
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News Article
Catherine died on the operating table. Now police are investigating
Patient Safety Learning posted a news article in News
Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back. At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure. Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year. Catherine's family are now demanding a new inquest into her death in 2007. This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation. Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest. Read full story (paywalled) Source: The Times, 31 March 2024 -
News ArticleFamilies have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation. This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome. The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case. “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.” Read full story (paywalled) Source: HSJ, 2 April 2024
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News Article
Vulnerable Britons dying as not being given antibiotics at dentist, doctors say
Patient Safety Learning posted a news article in News
Patients are dying needlessly every year due to vulnerable Britons with heart problems not being given antibiotics when they visit the dentist, doctors have said. Almost 400,000 people in the UK are at high risk of developing life-threatening infective endocarditis any time they have dental treatment, the medics say. The condition kills 30% of sufferers within a year. A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year are getting the disease and up to 78 dying from it, they add. That policy may have caused up to 2,010 deaths over the last 16 years, it is claimed. That danger has arisen because the National Institute for Health and Care Excellence (NICE) does not follow international good medical practice and tell dentists to give at-risk patients antibiotics before they have a tooth extracted, root canal treatment or even have scale removed, the experts claim. The doctors – who include a professor of dentistry, two leading cardiologists and a professor of infectious diseases – have outlined their concerns in The Lancet medical journal. In it, they urge NICE to rethink its approach in order to save lives, citing pivotal evidence that has emerged since the regulator last examined the issue in 2015, which shows that antibiotics are “safe, cost-effective and efficacious”. Read full story Source: The Guardian, 2 April 2024 -
News Article
Long A&E wait times lead to more than 250 needless deaths a week
Patient Safety Learning posted a news article in News
More than 250 patients a week could be dying unnecessarily, due to long waits in A&E in England, according to analysis of NHS data. The Royal College of Emergency Medicine analysed the 1.5 million who waited 12 hours or more to be admitted in 2023. A previous data study had calculated the level of risk of people dying after long waits to start treatment and found it got worse after five hours. The government says the number seen within a four-hour target is improving. This is despite February seeing the highest number of attendances to A&E on record, it adds. The Royal College of Emergency Medicine (RCEM) carried out a similar analysis in 2022, which at that time resulted in an estimate of 300-500 excess deaths - more deaths than would be expected - each week. The analysis uses a statistical model based on a large study of more than five million NHS patients that was published in 2021. RCEM president Dr Adrian Boyle said long waits were continuing to put patients at risk of serious harm. "In 2023, more than 1.5 million patients waited 12 hours or more in major emergency departments, with 65% of those awaiting admission," he said. "Lack of hospital capacity means that patients are staying in longer than necessary and continue to be cared for by emergency department staff, often in clinically inappropriate areas such as corridors or ambulances. "The direct correlation between delays and mortality rates is clear. Patients are being subjected to avoidable harm." Read full story Source: BBC News, 1 April 2024 -
Content ArticleThe idea of Emergency care services experiencing seasonal spikes in demand – so called ‘Winter Pressures’ are fast becoming a thing of the past. Instead, long waits have become the new norm year-round, and staff are caring for patients in unsafe conditions on a daily basis. It is well established that long waits are associated with patient harm and excess deaths. Last year the UK Government published a Delivery Plan for the Recovery of Urgent and Emergency Care (UEC) services. A year on, far too many patients are still coming to avoidable harm. New analysis by the Royal College of Emergency Medicine (RCEM) reveals that there were almost 300 deaths a week associated with long A&E waits in 2023.
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Content ArticleMedical errors happen all the time. They can be overlooked or they can lead to big lawsuits and settlements. But what they rarely lead to is an apology. However, increasingly, patients, families and healthcare professionals, are calling for a new approach, one that acknowledges the lasting damage that comes from a failure to address medical mistakes. In this report for US media company NPR, a Naomi and Jeff tell their story of losing their daughter Thalia to medical error following planned surgery. They report that concerns they and Thalia raised about their breathing were ignored by healthcare professionals, and Thalia died after her brain was starved of oxygen. The hospital didn't give an explanation or apology for Thalia's death.
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News ArticlePatients at the hospital that treated killer Valdo Calocane were discharged too soon and released in a worse state into the community, the NHS safety watchdog has found. Serious failings by Nottinghamshire Hospital Foundation Trust in keeping patients and the public safe have been identified in a review from the Care Quality Commission (CQC). More than 1,200 patients are waiting to be seen by community services, the report found. Meanwhile, several hundred who are receiving treatment did not have a clinician overseeing their care,the CQC found. The review was launched by the government following the conviction of killer Valdo Calocane, who was under the care of the NHS trust’s community services. The CQC review said patients reported that crisis services are either “useless” or detrimental to their health. The three broad areas of concern, highlighted in the CQC’s report, were: High demand for services was leading to long waiting times for care and a lack of oversight of those waiting. The trust does not have enough staff to keep patients safe in the community and within some hospital services. Senior leaders at the trust do not have clear oversight of the risks and issues within the service. Read full story Source: The Independent, 27 March 2024
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Content ArticleFollowing the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008. As part of the review, CQC were asked to look at 3 specific areas: A rapid review of the available evidence related to the care of Valdo Calocane An assessment of patient safety and quality of care provided by NHFT An assessment of progress made at Rampton Hospital since the most recent CQC inspection activity In this report, CQC detail the findings of parts 2 and 3. They will publish a separate report on part 1 in relation to the care of VC in summer 2024.
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News Article
‘My child was drowning’: life and death on an English maternity ward
Patient Safety Learning posted a news article in News
Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss? The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned. “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter. “So Charlotte spent four years in agony,” says James, “thinking it was her.” Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says. Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”. James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them. “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says. Read full story Source: The Guardian, 26 March 2024 -
Content ArticleAlong with the Care Inspectorate, Healthcare Improvement Scotland have established a National hub for reviewing and learning from the deaths of children and young people (National hub). The National hub uses evidence to deliver change. It ultimately aims to help reduce preventable deaths and harm to children and young people.
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News Article
Rollout of new death certification system could be delayed again
Patient Safety Learning posted a news article in News
A new system requiring GPs to agree death certificates with a medical examiner is unlikely to launch at the beginning of April, it has emerged. The system, which will see medical examiners (MEs) providing independent scrutiny of all deaths in the community which are not taken to the coroner, had previously been due to come in from April last year. However, it was delayed by one year to allow time for Parliament to introduce the necessary supporting legislation and, according to the Department of Health and Social Care (DHSC), this has yet to happen. A spokesperson told Pulse that the Government’s intention is to still introduce secondary legislation ‘from April’ to implement death certification reform. However, it could not confirm the exact date the system will launch and said it would provide an update before the end of March. Nottingham GP Dr Irfan Malik told Pulse that local GPs and practice staff ‘seem to be aware there is a delay’ but have had ‘no official emails’ or communication confirming the delays. Read full story Source: Pulse, 20 March 2024 -
News Article
Health board not learning from preventable deaths
Patient Safety Learning posted a news article in News
Lessons have not been learned to prevent further deaths in north Wales, coroners have told the health secretary. Over the past year, coroners in Wales wrote 41 "prevention of future deaths reports" and more than half were issued to Betsi Cadwaladr health board. Health Secretary, Eluned Morgan, said 27 reports issued since January 2023 was "of significant concern". Betsi Cadwaladr health board said every report was taken very seriously and work was ongoing to respond to key themes. Ms Morgan said all but three of the deaths happened before the health board was moved back into special measures in February 2023. The "systemic issues" that emerge as common themes from the coroners' reports include: the quality of investigations and effectiveness of actions a lack of integrated electronic health records impacting care the impact of delays in the system on ambulance response times. In a written statement earlier this week, Ms Morgan said the health board had given assurances that it was taking the matter "extremely seriously". Read full story Source: BBC News, 21 March 2024 -
Content ArticleThis report outlines the findings of an independent investigation into the conduct of a spinal consultant, Doctor F, who formerly worked at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust).
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News Article
Campaigner: Mental health 'deaths crisis' getting worse
Patient Safety Learning posted a news article in News
A campaigner in Norfolk says the "deaths crisis" at the county's mental health trust is getting worse. Bereaved relatives met the mental health minister, Maria Caulfield, to discuss failings at the Norfolk and Suffolk NHS Foundation Trust (NSFT). The trust says it is on a "rapid, and much-needed journey of improvement". Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "We judge people by what they do, not what they say." Members of the campaign group met Ms Caulfield and other MPs in Westminster on 12 March and demanded an independent public inquiry into the trust. It came after a report last summer which found that more than 8,000 mental health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. At the meeting, it was agreed Ms Caulfield would meet bosses at the NSFT. The health select committee will also be asked to conduct an inquiry into the trust as part of a broader public inquiry. But Mr Harrison said he had little confidence anything would change. "The deaths crisis is just out of control and it's accelerating," he said. "We have been doing this for 10 years. Every time somebody promises to do something, it doesn't come to anything." Read full story Source: BBC News, 20 March 2024 -
News ArticleAn inquest into the death of a baby boy who died two weeks after birth in a Sussex hospital has found there were missed opportunities in the care of his mother. Orlando Davis was born by emergency caesarian section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on 10 September 2021 following a normal and low risk pregnancy. He was born with no heartbeat and his parents were told he had suffered an irreversible brain injury after being starved of oxygen - after his mother Robyn Davis experienced seizures during labour, caused by a rare condition that went "completely unrecognised" by staff. Orlando died in Robyn and husband Jonny’s arms on 24 September 2021 at 14 days old due to his catastrophic brain injury. His mother had to be put in an induced coma, but has since recovered. But his parents say his death was avoidable. Today at the inquest into Orlando's death, senior coroner, Ms Penelope Schofield said a lack of understanding of hyponatremia contributed to neglect of Orlando. Mrs Davis had told the inquest: “I can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the trust for not keeping us safe. Mrs Davis continued: “The thing I cannot process is that I have lost my healthy, full-term son. I feel as if my son was taken from me in a circumstance that, in my personal and professional opinion, was completely preventable. Read full story Source: ITVX, 14 March 2024
