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Showing results for tags 'Patient death'.
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News Article
Specialist NHS centres aim to halve maternity deaths in England
Patient Safety Learning posted a news article in News
Women at risk of dying in pregnancy or childbirth will be treated at a network of specialist NHS centres under a national drive to halve maternal deaths. For the first time, women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy. Two thirds of maternal deaths in the UK are due to medical conditions that pre-date or develop during pregnancy, rather than direct complications of birth. Previously there was no dedicated national service for these women. The 17 NHS centres, covering every region of the country, aim to prevent these deaths by bringing together specialist doctors, obstetricians, midwives and nurses under one roof. GPs and A&E staff will also be trained to identify “red flag” symptoms of illnesses in pregnant women and refer patients directly to the centres, where they can be assessed and receive medication or procedures. Read full story (paywalled) Source: The Times, 20 March 2023 -
News Article
My daughter took her own life after pain caused by mesh surgery
Patient Safety Learning posted a news article in News
A woman whose daughter took her own life after being left in chronic pain caused by giving birth has spoken of her family's heartbreak. Sara Baines, 34, from Flintshire, died in September last year leaving her family devastated. This week an inquest heard Sara suffered from chronic pain due to complications resulting from surgical mesh that was implanted after she gave birth in 2011. Her mother, Alison Sharrock, says Sara was failed by the health system on multiple occasions. Sara bled heavily whilst giving birth and suffered a second-degree tear. She had to have two surgeries to repair the tear, neither of which was completely successful. Sara found herself completely incontinent, at the age of 24. In 2015, Sara was advised to have mesh fitted. Alison said: "We were told the mesh was a 'quick-fix'. It felt like the answer to all her problems and she was thrilled. She had surgery but afterwards, though the incontinence improved, she had terrible abdominal pain." The pain became so severe that Sara was offered a hysterectomy, aged 28. Afterwards, the pain only intensified, and her general health deteriorated. She suffered water infections, skin rashes, gum disease and unexplained pain. Unable to eat or sleep, she became depressed and anxious. "She felt nobody was really listening to her. She felt she was gaslighted and fobbed off," said Alison. Kath Sansom, founder of Sling The Mesh which has almost 10,000 members suffering irreversible pan and complications from surgical mesh implants, said: "Our hearts go out to Sara's family. Nine out of 10 people in our support group were not told any risks of having a plastic mesh permanently implanted." Read full story Source: Mail Online, 24 March 2023 Further reading on the hub: Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery ‘Mesh removal surgery is a postcode lottery’ - patients harmed by surgical mesh need accessible, consistent treatment -
News Article
Apologies for 2013 mental health failings over mum
Patient Safety Learning posted a news article in News
A son has accepted a settlement and an apology from the north Wales health board nearly 10 years after his mother was a patient in a mental health unit. Jean Graves spent nine weeks at the Hergest unit in Ysbyty Gwynedd in Bangor in 2013 after struggling with anxiety and depression. Her son David said she was left "severely malnourished" and fell. He previously said his mother - who was 78 when she was treated at the unit - collapsed six times and, over the course of six weeks, lost 25% of her body mass. The health board also apologised for the "distress" the family experienced while seeking answers "over many years" and said it hopes to "learn and improve" from Mr Graves's experience. In a letter to him, executives said: "It is very clear to us that we have failed your mother and that she should have had a better care whilst in our services." It said her records were incomplete or were "amended without proper evidence" and she was placed on a ward with a mix of patients with both psychiatric illness and older organic mental illness, which was not "best practice". Read full story Source: BBC News, 26 March 2023 -
News Article
Australia: brain surgeon defends slapping patient after surgery
Patient Safety Learning posted a news article in News
The high-profile Australian neurosurgeon Charlie Teo admits making an error by going “too far” and damaging a patient, but maintains she was told of the risks. The doctor on Monday appeared at a medical disciplinary hearing to explain how two women patients ended up with catastrophic brain injuries. Teo also defended allegations that he acted inappropriately by slapping a patient in an attempt to rouse her after surgery, contrasting it with Will Smith’s notorious slap of Chris Rock at the Academy Awards last year. “It wakes them up and it wakes them up pretty quickly. And I will continue to do it.” Charlie Teo tells inquiry he ‘did the wrong thing’ in surgery that left patient in vegetative state One of the issues the panel of legal and medical experts is considering is whether the women and their families were adequately informed of the risks of surgery. Both women had terminal brain tumours and had been given from weeks to months to live. They were left in essentially vegetative states after the surgeries and died soon after. “We were told he could give us more time,” one of the husbands said, according to court documents. “There was never any information about not coming out of it". Read full story Source: The Guardian, 27 March 2023 -
News Article
Man died of sepsis after being sent home from Milton Keynes Hospital A&E
Patient Safety Learning posted a news article in News
A father-of-two died of sepsis three days after being sent home from A&E with antibiotics for a suspected urinary tract infection, an inquest heard. Alex Blewitt, 48, died in July 2022 after suffering a cardiac arrest caused by a perforated bowel and sepsis. Senior coroner for Milton Keynes, Dr Sean Cummings, said Mr Blewitt's death was avoidable. The coroner recorded a narrative conclusion and said he intended to issue a prevention of future deaths report. Mr Cummings said: "The doctor, who saw and assessed Mr Blewitt in the emergency department, did not read the Urgent Care Centre communication that was provided and did not record important factual information in the clinical note. "Mr Blewitt was discharged, but returned two days later when suffering with sepsis due to a previously undiagnosed bowel perforation." Mr Blewitt's widow, Amy Blewitt, said: "Alex was in such pain and kept asking the hospital for help, but they sent him home. "My plea to the hospital is please, please don't let this type of mistake ever happen to anyone else ever again." Read full story Source: BBC News, 22 March 2023 -
News Article
Trust told to pay more than £200k over dementia patient’s death
Patient Safety Learning posted a news article in News
A hospital trust has been told to pay almost a quarter of a million pounds after pleading guilty to failing to provide safe care to a patient with advanced dementia who fatally injured himself. The Care Quality Commission (CQC) brought the prosecution against University Hospitals of Derby and Burton Foundation Trust after an incident in July 2019, when a patient died after absconding from the hospital. Peter Mullis – who had advanced dementia – was admitted to Queen’s Hospital Burton emergency department and absconded twice. When he tried to a third time, he was followed by trust staff. The CQC described how, despite being followed, Mr Mullis was able to climb over a barrier, fall down a grass bank and hit his head on concrete at the bottom. He was airlifted to the local trauma centre, but died of multiple traumatic injuries. The CQC said UHDB did not take “reasonable steps” to ensure safe care was provided and that failure exposed Mr Mullis to “significant risk of avoidable harm”. -
News Article
Why US mothers are more likely to die in childbirth
Patient Safety Learning posted a news article in News
The United States remains one of the most dangerous wealthy nations for a woman to give birth. Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention. In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC. Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank. "Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US." Read full story Source: BBC News, 18 March 2023 -
News Article
UK life expectancy growing at slower rate than rest of G7, research shows
Patient Safety Learning posted a news article in News
Life expectancy in the UK has grown at a slower rate than comparable countries over the past seven decades, according to researchers, who say this is the result of widening inequality. The UK lags behind all other countries in the group of G7 advanced economies except the US, according to a new analysis of global life expectancy rankings published in the Journal of the Royal Society of Medicine. While life expectancy has increased in absolute terms, similar countries have experienced larger increases, they wrote. In the 1950s, the UK had one of the longest life expectancies in the world, ranking seventh globally behind countries such as Denmark, Norway and Sweden, but in 2021 the UK was ranked 29th. The researchers said this was partly due to income inequality, which rose considerably in the UK during and after the 1980s. Prof Martin McKee, of the London School of Hygiene & Tropical Medicine, said: “That rise also saw an increase in the variation in life expectancy between different social groups. One reason why the overall increase in life expectancy has been so sluggish in the UK is that in recent years it has fallen for poorer groups". Read full story Source: The Guardian, 16 March 2023 -
News Article
USA: Rise in infant deaths hits Black families hardest, study finds
Patient Safety Learning posted a news article in News
A new US study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths (SIDS) in 2020, dying at almost three times the rate of White infants. The findings were part of research by the Centers for Disease Control and Prevention, which also found a 15% increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth. “In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore. The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities. Read full story (paywalled) Source: The Washington Post, 13 March 2023 -
Content ArticleOn 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the ambulance navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind’s condition continued to deteriorate and she died at 17.52 hours.
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Content ArticleAfter Steve Burrow’s mother was harmed by medical care in Wisconsin, he took time out from his successful film career to advocate for her. In this episode of Lit Health, he touches upon his fascinating career, why stories matter, and delves deeply into his experience with the medical system, its need for policy reform and the role he has taken on as an advocate in this space with host, Tracy Granzyk. Lit Health podcasts interview authors, healthcare leaders, and policymakers working to create a healthcare environment that is equitable, transparent, and that welcomes the needs of every patient – especially our vulnerable populations including the mentally ill, people of colour and women who feel they are at risk in our current system, the elderly, and anyone who feels bias or the isms affect their health and quality of life. You can also watch Steve Burrow's documentary: Bleed Out,
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Content ArticleAhead of World Cancer Day 2023, Cancer Research UK have published a new report that shows that the impact of cancer for people in the UK will only grow, and sets out the challenges that cancer services are already facing today. New modelling published in the report, Cancer in the UK: Overview 2023 shows that if current trends continue, cancer cases will rise from the 384,000 diagnosed each year now, to over half a million by 2040. To put that into context, that means around a third more people will be diagnosed with the condition every year in comparison to current levels. And we could see around a quarter more annual cancer deaths – 208,000 by 2040, With services barely treading water now, Governments across the UK must act if they are to effectively meet the increase in demand that this analysis anticipates, but efforts have been piecemeal so far.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aims to improve patient safety by supporting staff to access critical information about patients at their bedsides in emergency situations. It defines critical information as ‘information about patients that needs to be accessed rapidly and accurately to ensure correct care is delivered when it is required’. In this investigation, critical information was considered through a focus on patient identifiers (such as name and date of birth) and decisions relating to whether someone is recommended to receive cardiopulmonary resuscitation (CPR) if their heart stops (cardiac arrest). The reference event for this investigation was the care of a patient in a hospital who was found unresponsive in bed. A short time later, he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the patient’s bed, where they confirmed the patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. As a result, CPR was not started. Around 10 minutes later, a nurse who had previously been caring for the patient returned from their break and recognised that the patient had been misidentified as the patient in the next bed. The patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the patient died.
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Content ArticleIn this video, Leah Coufal’s mother, Lenore Alexander, recounts the tragic story of her 12-year-old daughter’s preventable death in hospital in December 2002. Leah died from opioid-induced respiratory depression due to a lack of continuous postoperative monitoring which could have saved her life. Lenore now campaigns for the legal requirement to monitor patients on opioids after surgery.
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Content ArticleThis is a brief summary of a Westminster Hall debate in the House of Commons on the 31 January 2023 concerning the Essex Mental Health Independent Inquiry.
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Content ArticleThis prevention of future deaths report looks at the death of Ben King, who died of acute respiratory failure, obesity hypoventilation syndrome and use of sedative medication. Ben had Down's Syndrome and obstructive sleep apnoea and had been detained under the Mental Health Act at Jeesal Cawston Park (JCP) from 2018. Ben’s weight as at June 2019 was recorded at 85.2 kg which had risen to 106 kg by June 2020. He was given the sedative Promethazine after becoming agitated and found unresponsive on 29 July 2020. He died later that day at Norfolk and Norwich University Hospital.
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Content ArticleThis report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
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Content ArticleOn 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
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Content ArticleThis video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
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Content Article
The average life expectancy for people with a learning disability is significantly lower than for the general population. Sadly, many of these premature deaths are avoidable. Mandy Anderton is a Clinical Nurse specialising in learning disability. In this interview she explains some of the barriers people with a learning disability face in accessing safe care and how adjustments can be made within GP practices to improve outcomes. Mandy ends with a list of national improvements that she believes would reduce health inequalities in this area. -
Content ArticleThis study examined the risks and patterns of childhood deaths before and during the COVID-19 pandemic. In this cohort study, there were 3409 childhood deaths from April 2019 to March 2020, 3035 deaths from April 2020 to March 2021, and 3428 deaths from April 2021 to March 2022. Overall risk of death was significantly lower from 2020 to 2021, but not from 2021 to 2022 when compared with the reference year of 2019 to 2020. These findings suggest that there was a significant reduction in all-cause child mortality during the first year of the COVID-19 pandemic (2020-2021), which returned to near prepandemic levels the following year (2021-2022).
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Content Article
In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism. -
Content ArticleA prolonged stay in the emergency department before moving on to an in-hospital bed, another facility or departing home, is believed to have a negative effect on clinical outcomes for patients. This international systematic review and meta-analysis in the Journal of Clinical Medicine aimed to investigate the link between emergency department length of stay (EDLOS) and in-hospital mortality. The study's findings suggest two key associations with increased in-hospital mortality: low EDLOS EDLOS exceeding 24 hours The authors suggest that: long stays in the emergency department should not be allowed. special attention should be given to patients admitted after a short stay in the emergency department.
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Content ArticleThe NHS is the pride of Britain. It’s an army of highly skilled and talented healthcare professionals, armed with the most cutting-edge therapies and medicines, and a budget bigger than the GDP of most countries in the world. Yet avoidable failures are common. And the result is tragic deaths up and down the country every day. Jeremy Hunt, the longest-serving Health Secretary in history, knows exactly what the cost is. In the letters he received from bereaved family members, he was constantly confronted by the heart-breaking reality of slip-ups and mistakes. There is increasing conflict between public pride in the NHS and the exhausted daily reality for many doctors and nurses, now experiencing burnout in record numbers. Waiting lists are up, staffing numbers inadequate, and all the while an ageing population and medical advances increase both demand and expectations. With pressures like these, is it surprising that mistakes start to creep in? This great British institution is crying out for renewal. In Zero, taking the broadest approach, thinking through everything from staffing to technology, budgets to culture, Hunt presents a manifesto for that renewal.
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Content ArticleIn December 2022, the All Party Parliamentary (APPG) for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed. This blog first appeared on the Whistleblowers UK website in December 2022.
