Jump to content

Search the hub

Showing results for tags 'Patient death'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


Join a private group (if appropriate)


About me


Organisation


Role

Found 1,460 results
  1. Content Article
    Benjamin Lee Stroud died on the 19 March 2021 at home. He lived alone but had a partner who saw him regularly. He had a previous medical history of recreational drugs, including steroids and cannabis; he was recently diagnosed as insulin dependent diabetic and had undergone a kidney transplant. He fell and injured his back at work, and developed a dependence on pain medication, some of which were purchased on the internet. His mental health issues increased as a result of his psychical health problems. A post mortem was undertaken and the cause of death was multiple drug toxicity.
  2. Content Article
    Barbara Young fell downstairs at her home at 11.30am on 15 July 2021, sustaining multiple injuries including fractures of her ribs, spine and skull. Her family immediately called the emergency services and informed the ambulance call handlers that she had fallen downstairs, was not fully conscious and had sustained an apparently severe head injury. An ambulance subsequently arrived at 2.26pm and she was taken to hospital where, due to her reduced mobility, she developed pneumonia. Mrs Young’s conditioned worsened over the coming days and she died on 24 July 2021.  In her report, the Coroner raises concerns about the ambulance waiting time in this case, and more generally about ambulance response times in cases where elderly patients experience falls.
  3. Content Article
    On the 15 May 2020, John Skinner was admitted to Watford Hospltal suffering from a tonic clonlc seizure. He had a background of cannabis usage and a subdural empyema in 2020 that had left him with epilepsy. On arrival at hospital he again had another tonic clonlc seizure and focal seizures. The Junior doctor Instructed to administer the drug sought advice from a more senior doctor as to the dose to be administered. As a result of a failure In verbal communication between the doctors, aggravated as both were masked, a dose of 15 mg/kg was heard as 50 mg/kg and an overdose was administered. He was given 3600 mg of phenytoln. He arrested within 16 minutes and died and could not be revived. 
  4. Content Article
    This report was commissioned by the Royal College of Obstetricians and Gynaecologists, with research led by Leeds Beckett University in collaboration with the University of Sheffield and the University of Oxford. It aims to inform those involved in the care of pregnant women in the UK about the relationship between social determinants of health and the risk of maternal death.
  5. Content Article
    COVID-19 has meant people have died the ultimate medicalised deaths, often alone in hospitals with little communication with their families. But in other settings, including in some lower income countries, many people remain undertreated, dying of preventable conditions and without access to basic pain relief. The unbalanced and contradictory picture of death and dying is the basis for the Lancet Commission on the Value of Death. Drawing on multidisciplinary perspectives from around the globe, the Commissioners argue that death and life are bound together: without death there would be no life. The Commission proposes a new vision for death and dying, with greater community involvement alongside health and social care services, and increased bereavement support.
  6. Event
    This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email kate@hc-uk.org.uk hub members receive 20% off. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
  7. Event
    This national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious Incident Framework. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. The conference is particularly timely considering the current Essex Mental Health Independent Inquiry which has National Implications. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-serious-incidents-in-mental-health-services or email: frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow this conference on Twitter @HCUK_Clare #SIMental
  8. Event
    This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email aman@hc-uk.org.uk. With only a few places left, HCUK are offering hub members five discounted places at only £195+VAT with discount code HCUK195PSL. Follow the conference on Twitter @HCUK_Clare #LFDNHS
  9. Event
    This national conference looks at the practicalities of serious incident investigation and learning from deaths in mental health services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which was published on 16 August 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. Register
  10. Event
    This conference focuses on investigating and learning from deaths in the community/primary care. The conference focuses on the extension of the Medical Examiner role to cover deaths occurring in the community and the role of the GP in working with the Medical Examiner to learn from deaths and to identify constructive learning to improve care for patients. The conference will also focus on implementation of the new Patient Safety Incident Response Framework and learning from a primary care early adopter. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-community or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningfromdeathsPC
  11. Community Post
    About 1000 angry nurses and doctors have rallied outside Perth Children’s Hospital in Australia following the death of seven-year-old Aishwarya Aswath, demanding vital improvements to the state’s struggling health system. The Australian Nurses Federation was joined by the Australian Medical Association for the rally, with staff from hospitals across Perth attending. Many people held signs that read “We care about Aishwarya”, “Listen to frontline staff”, “Report the executive — not us” and “Please don’t throw me under the bus”. Aishwarya developed a fever on Good Friday and was taken to Perth Children’s Hospital the next day, but had to wait about two hours in the emergency department before she received treatment. She died soon after from a bacterial infection. An internal report into the tragedy made 11 recommendations — including improvement to the triage process, a clear way for parents to escalate concerns and a review of cultural awareness for staff — but Aishwarya’s parents said the report raised more questions than it answered. The family wants a broader independent inquiry to look at all 21 near-misses in the past 15 months – not just their daughter’s case. Some people have been referred to medical authorities, while Child and Adolescent Health Service chair Debbie Karasinski resigned after the report.' I am encouraged to see the way healthcare staff reacted to this tragedy. Imagine a similar event in England, would nurses protest outside the hospital and stand up to authority like this? I doubt it very much, which is very sad reflection on the prevailing culture and health leadership in England. What do others think? Source: The Australian. 9 July 2021 Picture: Picture: 9 News
  12. Community Post
    We should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
  13. Community Post
    See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
  14. Content Article
    The objective of this study, published in the BMJ, was to determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI). Authors conclude that reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist.
  15. Content Article
    At the time of her death, Heather Findlay, aged 28 years, was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. At inquest, the jury came to a conclusion of death by suicide and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity.
  16. Content Article
    A vision for improving the care and support available to families when baby loss occurs before 24 weeks' gestation.
  17. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services.
  18. Community Post
    I’ve just been listening to the 10 o’clock news tonight and it has been covering the report into Paterson, the breast surgeon who may have needlessly operated on thousands on women. One of the recommendations is that patient safety should be a ‘top priority’ across the NHS (again!!). Another interesting recommendation is that the NHS (and private healthcare providers) need to be better at sharing information about medical staff. Currently, medical staff seem to be able to be investigated in one hospital, and then move to another without any of their history following them. Maybe we need some sort of central system, like Doctify for employers? What do you think?
  19. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  20. Community Post
    Does anyone have examples of templates they use for reviewing unexpected deaths in the community of patients known to mental health services?
  21. Content Article
    Food allergy affects around 7-8% of children worldwide, or about two children in an average-sized classroom. As children spend at least 20% of their waking hours in school, it is not surprising that data show that 18% of food allergy reactions and 25% of first-time anaphylactic reactions occur at school. This report by the Benedict Blythe Foundations looks at the prevalence and seriousness of allergies in school-aged children, and the devastating consequences when things go wrong at school.
  22. Content Article
    NHS England commissioned a limited scope independent review into patient safety concerns and governance processes related to the North East Ambulance Service. Chaired by Dame Marianne Griffiths DBE, the review considered the facts surrounding a number of individual cases, reviewed the processes surrounding coronial investigations and reviewed the seven previous investigations and reviews undertaken by the ambulance service to determine if they were sufficient to fully understand and resolve issues.
  23. Content Article
    Gloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
  24. Content Article
    This policy explains how the Structured Judgement Review (SJR) process is implemented within Maidstone and Tunbridge Wells NHS Trust. The policy advises staff on how to undertake a mortality case record review, which documentation to use, in which circumstances an SJR is required and how the new process relates to previous systems and processes. The policy also explains how the process links to revised mortality reporting, escalation of concerns and dissemination of learning. It covers all inpatients and Emergency Department patients who die whilst in the Trust’s care, and patients who die within 30 days of discharge.
×
×
  • Create New...