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Found 1,486 results
  1. Content Article
    The National Coronial Information System (NCIS) is an online repository of coronial data from Australia and New Zealand.
  2. Content Article
    This is the video recording of a House of Lords debate on the delivery of maternity services in England, put forward by Baroness Taylor of Bolton.
  3. News Article
    Paramedics are "watching their patients die in the back of ambulances because they can't get them into A&E", according to the health union, Unison. It was commenting on data showing 2,750 hours were lost by ambulance crews waiting to hand over patients at Hull Royal Infirmary in October 2023. One crew was stuck outside A&E for 10 hours and 27 minutes. Hull University Teaching Hospitals said it was "confident" a new urgent treatment centre on the hospital site would "improve overall waiting times" and lost ambulance hours had "reduced notably" this month. The figures, obtained by the BBC through a freedom of information request, showed on 9 October 2023 ambulance crews lost 144 hours and 18 minutes, the equivalent to one crew being out of action for six full days and nights. Megan Ollerhead, Unison's ambulance lead in Yorkshire, said paramedics were "literally watching their patients die in the back of these ambulances because they can't get into A and E." "I talk to a lot of the people who receive the 999 calls in the control rooms and they're just listening to people begging for ambulances and they know there are none to send." Read full story Source: BBC News, 26 January 2024
  4. News Article
    Doctors "failed to realise" that a first-time mother's pregnancy had become "much higher risk" because crucial warning signs were not properly highlighted in her medical records, an inquiry has heard. Nicola McCormick was obese and had experienced repeated episodes of bleeding and reduced foetal movement, but was wrongly downgraded from a high to low risk patient weeks before she went into labour. Her daughter, Ellie McCormick, had to be resuscitated after being born "floppy" with "no signs of life" at Wishaw General hospital on March 4 2019 following an emergency caesarean. She had suffered severe brain damage and multi-organ failure due to oxygen deprivation, and was just five hours old when her life support was switched off. A fatal accident inquiry (FAI) at Glasgow Sheriff Court was told that Ms McCormick, who was 20 and lived with her parents in Uddingston, should have been booked for an induction of labour "no later" than her due date of 26 February. Had this occurred, she would have been in hospital for the duration of the birth with Ellie's foetal heartbeat "continuously" monitored. In the event, Ms McCormick had been in labour for more than nine hours by the time she was admitted to hospital at 8.29pm on 4 March. A midwife raised the alarm after detecting a dangerously low foetal heartbeat, and Ms McCormick was rushed into theatre for an emergency C-section. Dr Rhona Hughes, a retired consultant obstetrician who gave evidence as an expert witness, told the FAI that Ellie might have survived had there been different guidelines in place in relation to the dangers of bleeding late in pregnancy, or had her medical history been more obvious in computer records. Read full story Source: The Herald, 24 January 2024
  5. Content Article
    This investigation looks into patient safety issues associated with airway management – the techniques used by healthcare professionals to help patients to get enough oxygen into their lungs, for example during surgery or a medical emergency. The reports findings, safety recommendations and safety observations are intended to help healthcare professionals quickly recognise whether someone has a potentially difficult airway and may need advanced airway management techniques to keep their airway open.
  6. News Article
    The rate at which people are dying early from heart and circulatory diseases has risen to its highest level in more than a decade, figures show. Data analysed by the British Heart Foundation (BHF) shows a reverse of previous falling trends when it comes to people dying from heart problems before the age of 75 in England. Since 2020, the premature death rate for cardiovascular disease has risen year-on-year, with the latest figures for 2022 showing it reached 80 per 100,000 people in England in 2022 – the highest rate since 2011 when it was 83. This is the first time there has been a clear reversal in the trend for almost 60 years. Between 2012 and 2019 progress slowed and, from 2020, premature death rates began to clearly rise, the data reveals. Dr Sonya Babu-Narayan, associate medical director at the BHF and a consultant cardiologist, said: “We’re in the grip of the worst heart care crisis in living memory. “Every part of the system providing heart care is damaged, from prevention, diagnosis, treatment, and recovery; to crucial research that could give us faster and better treatments. “This is happening at a time when more people are getting sicker and need the NHS more than ever. “I find it tragic that we’ve lost hard-won progress to reduce early death from cardiovascular disease.” Read full story Source: Medscape, 22 January 2024
  7. Content Article
    On the 9 December 2022, Dennis John William King suffered sudden chest pain which extended down his arm. His wife called 999 and spoke with an ambulance service call handler. Following triage of the call, the response to Mr King's call was graded as a Category 3 (a potentially urgent condition which is not life threatening with a target response of 120 minutes). This call was subsequently re-graded following review in the call centre to a Category 2 (a potentially serious condition requiring rapid assessment, urgent on scene intervention or transport to hospital, with a response within 40 minutes and a target of 18 minutes).   Upon hearing that the waiting time for an ambulance could be as long as six hour, Mr and Mrs King decided to make their own way to the West Suffolk Hospital. The ambulance service were advised and the response stood down.   Within 40 minutes of arrival Mr King had been diagnosed as suffering an ST segment elevation myocardial infarction (STEMI). Treating clinicians assessed his condition as necessitating an urgent transfer to the Royal Papworth and for the angioplasty procedure to be conducted forthwith. The ambulance call centre was contacted by the hospital emergency department with a request for an urgent transfer to the Royal Papworth. Emergency department staff were advised that there would be a 5 hour delay for an ambulance to attend. The call from the hospital emergency department to the ambulance service was graded by the ambulance call handler as a category 2 response. When the response timing was challenged the emergency department matron was advised that the hospital was a place of safety. The ambulance call handler assessment did not seem to take into account the clinical assessment of accident and emergency department staff who, in consultation with the regional cardiac intervention hospital, had determined Mr King's further treatment at the regional cardiac centre was a matter of urgency. An ambulance subsequently arrived at West Suffolk Hospital Accident and Emergency Department and transferred Mr King to the Royal Papworth Hospital where he underwent treatment for what was identified as an occluded left anterior descending artery. About 1 hour after the procedure, Mr King's condition deteriorated and he suffered a left ventricular wall rupture, a recognised complication of either the myocardial infarction he had suffered or the surgical procedure to correct the occluded artery, or both. He received emergency surgery to repair the rupture by way of a patch which was successful. However, his condition deteriorated and he died on the 13 December 2022. The medical cause of death was confirmed as: 1a Multi Organ Failure 1b Post myocardial infarction left ventricular free wall rupture (operated on).
  8. News Article
    The availability of ambulances to transfer patients to specialist units is a "matter of concern", a coroner has warned. Darren Stewart, area coroner for Suffolk, made the comments in a Prevention of Future Deaths report. It followed the death of 84-year-old Dennis King, who waited three hours to be transferred from West Suffolk Hospital to Royal Papworth in 2022. Mr King had made his own way to the West Suffolk Hospital's accident and emergency department in December 2022, after being told an ambulance could take six hours to arrive at his home due to high demand in the area, the report said. His call had been graded as category two, which should have led to a response within 40 minutes - or a target of 18 minutes. After tests at West Suffolk Hospital showed Mr King had suffered a STEMI heart attack, emergency clinicians liaised with experts from the regional heart unit and decided he needed an urgent transfer to Royal Papworth in Cambridgeshire. The report said a matron at West Suffolk told ambulance call handlers they needed an urgent transfer - but because Mr King was classed as being in a "place of safety", control room staff said the delay would be "several hours". Mr Stewart said: "the availability of ambulances to carry out transfers in a timely manner, in urgent cases" was "a matter of concern". In the report, Mr Stewart said the circumstances of the case "raised concerns about the NHS approach to centralising care in regional centres" if the means to deliver it were "inadequate". Read full story Source: BBC News, 23 January 2024
  9. News Article
    The Campaign to Save Mental Health Services in Norfolk and Suffolk is calling for a criminal investigation into an apparent scandal that decisively surfaced over the summer, centred on the Norfolk and Suffolk NHS foundation trust (or NSFT), which sees to mental health provision across those two very large English counties. It is centred on the “unexpected” deaths of 8,440 people between April 2019 and October 2022, all of whom were either under the care of the trust, or had been up to six months before they died. The story of the failures that led to that statistic date back at least a decade; the campaign says it amounts to nothing less than “the largest deaths crisis in the history of the NHS”. The figure of 8,440 was the key finding of a report by the accounting and consultancy firm Grant Thornton – commissioned by the trust, ironically enough, to respond to anxious claims by campaigners, disputed by the trust, that there had been 1,000 unexpected deaths over nine years. There are no consistent national statistics for such deaths, and no universal definition of “unexpected”: in Norfolk and Suffolk, a death will be recorded as such if the person concerned was not identified by NHS staff as critically or terminally ill; the term includes deaths from natural causes as well as suicide, homicide, abuse and neglect. The period in question includes the worst of the pandemic, although the trust’s own annual deaths figures did not reach a peak until 2022-23. But the numbers still seem jaw-dropping: they represent an average of about 45 deaths a week. To put that in some kind of perspective, earlier reports about the trust’s deaths record had raised the alarm about a similar number of people dying every month. And the Grant Thornton report included another key revelation: the fact that the trust’s record-keeping was so chaotic that in about three-quarters of cases, it did not know the specifics of how or why the people concerned had died. After its publication, moreover, there were more revelations about the trust, and its culture and practices. Read full story Source: The Guardian, 21 January 2024
  10. Content Article
    In this article, Claire Brader summarises the recent findings on the performance of NHS maternity services in England, as well as recent government and NHS policies aimed at improving the quality of maternity care.
  11. Content Article
    Elizabeth Roberts was severely frail and bedbound, supported by visits from care agency carers four times per day and her local District Nursing Team. She had ischaemic and hypertensive heart disease and developed a large sacral sore with associated sepsis. She was admitted to Tameside General Hospital on 19 May 2023 where despite treatment, she died the same day of Sepsis with congestive cardiac failure. In this report the Coroner notes concerns about the her case and the capacity of the District Nursing Team providing here care.
  12. Content Article
    Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. The aim of this study published by Jama Internal Medicine was to determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalised adults transferred to an intensive care unit (ICU) or who died. The results showed that diagnostic errors were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
  13. News Article
    Patients have suffered cardiac arrests while waiting in A&E departments or in ambulances queueing outside because Scottish hospitals are overwhelmed, doctors have warned. At least three cases in which patients’ hearts stopped beating while they were waiting for care have been reported to the Royal College of Emergency Medicine in Scotland. Some of the incidents, the college said, may have been preventable. One frontline doctor told The Times that a patient with heart problems had died waiting in a queue of ambulances outside an emergency department. Staff could not take the patient inside because there was no capacity. JP Loughrey, vice-president of the college and an A&E consultant in the west of Scotland, said that people who should be in resuscitation rooms with a team of experts and equipment to monitor their vital signs were instead lying in ambulances outside hospital buildings. He also said that tensions were growing between frontline staff and NHS managers in large hospitals because doctors and nurses, who were already struggling to cope, were under increasing demands to work harder to process more patients. Read full story Source: The Times, 19 January 2024
  14. Content Article
    This podcast features Dr Alan Fletcher National Medical Examiner and Suzy Lishman, Senior Advisor on Medical Examiners at the Royal College of Pathologists discussing what the changes to death certification processes and new requirements to be introduced with the statutory medical examiner system will mean for medical examiners, medical examiner officers and others involved in death certification.
  15. News Article
    Fewer Americans are dying of cancer, part of a decades-long trend that began in the 1990s as more people quit smoking and doctors screened earlier for certain cancers. However, the American Cancer Society warned that those gains are threatened by an increase in cancers among people younger than 55, in particular cervical and colorectal cancer, and by the continued disparities between white Americans and people of colour. “The continuous sharp increase in colorectal cancer in younger Americans is alarming,” said Dr Ahmedin Jemal, senior vice-president for surveillance and health equity science at the American Cancer Society. “We need to halt and reverse this trend by increasing uptake of screening, including awareness of non-invasive stool tests with follow-up care, in people 45-49 years, [old]” said Jemal. Read full story Source: The Guardian, 17 January 2024
  16. Content Article
    These draft regulations from the Department of Health and Social Care set out how the statutory medical examiner system will operate in the NHS in England from April 2024. Medical examiners will be appointed by NHS bodies to provide independent scrutiny of causes of death and will be a contact for bereaved people who want to ask questions or raise concerns. The draft regulations set out: medical examiners’ terms of appointment, training and payment the procedure for independence additional functions
  17. News Article
    Large regional variations in the risk of death from cancer by the age of 80 have been revealed in research by Imperial College London based on NHS data for England. Analysis of the figures by The Independent shows the risk of dying is highest in northern England cities, while men and women living in the London boroughs had the lowest chance. Although the risk of dying from cancer has decreased across all areas of England in the last two decades, it is now the leading cause of death in England, having overtaken cardiovascular diseases. The Less Survivable Cancers Taskforce has that warned Britain has some of the worst cancer survival rates among the world’s wealthiest countries. It ranked the UK 28th out of 33 countries for five-year survival rate for stomach and lung cancer; for pancreatic cancer the UK was 26th, and it was 25th for brain cancer. Read full story Source: The Guardian, 13 January 2024
  18. Content Article
    When a family loses a loved one in unclear or unexplained circumstances, there is one thing that family members need above all else: answers. How did their loved one die, and could their death have been prevented? The Coroner Service is there to answer these questions. But in his annual report published in December, the chief coroner Judge Thomas Teague revealed the extensive delays now occurring in the coroners’ courts. In April 2021 more than 5,000 families waited over a year for the coroner to complete their investigations. This was a staggering increase on pre-pandemic figures, with 2,278 cases having lasted more than 12 months in 2019. And while figures from April 2022 suggest the backlog is gradually reducing (with 4,568 cases taking more than 12 months), it is clear that far too many families are still facing agonising delays, sometimes lasting several years.
  19. News Article
    “Better upfront planning, training and testing” were needed in a tech launch which was tied to patient harm and service disruption, an NHS England review has found. Royal Surrey and Ashford and St Peter’s Hospitals foundation trusts went live with Oracle Cerner’s electronic patient record in May 2022 – under a programme called Surrey Safe Care – but the implementation has since been linked to incidents of patient harm, including one death, and significant disruption to trust services. Now, a lessons learned review, carried out by NHSE’s frontline digitisation team and obtained by HSJ via a Freedom of Information request, has identified 24 areas of improvement. The key lessons cited by the review are “better upfront planning, roles and responsibilities, training and testing”. It recommended that, in future implementations, trust boards should be supported by others experienced with implementing EPRs within the NHS to “aid board level decisions and ‘what questions to ask when’”, while clearer responsibilities should also be agreed upon for programme leads and EPR suppliers. The review also found the content of training must be evaluated thoroughly, while the EPR supplier should provide “upfront and continuous training”. It added the “full end-to-end testing [by] representatives from all end user groups” should be completed before go-live. It also said EPR readiness needs to incorporate “data readiness, such as data quality, and mapping how data has originally been captured [which] may impact reporting and organisational readiness”. Read full story (paywalled) Source: HSJ, 15 January 2024 Related reading on the hub: NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn?
  20. Content Article
    This study published in JAMA Internal Medicine looked at how often diagnostic errors happened in adult patients who are transferred to the intensive care unit (ICU) or die in the hospital, what causes the errors, and what are the associated harms. In this cohort study of 2428 patient records, a missed or delayed diagnosis took place in 23%, with 17% of these errors causing temporary or permanent harm to patients. The underlying diagnostic process problems with greatest effect sizes associated with diagnostic errors, and which might be an initial focus for safety improvement efforts, were faults in testing and clinical assessment.
  21. News Article
    The number of women dying during pregnancy or soon after childbirth has reached its highest level in almost 20 years, according to new data. Experts have described the figures as “very worrying”. Between 2020 and 2022, 293 women in the UK died during pregnancy or within 42 days of the end of their pregnancy. With 21 deaths classified as coincidental, 272 in 2,028,543 pregnancies resulted in a maternal death rate of 13.41 per 100,000. This is a steep rise from the 8.79 deaths per 100,000 pregnancies in 2017 to 2019, the most recent three-year period with complete data. The death rate has increased to levels not seen since 2003 to 2005. The data comes from MBRRACE-UK, which conducts surveillance and investigates the causes of maternal deaths, stillbirths and infant deaths as part of the national Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). Urgent action is needed to bolster the quality of maternal healthcare, ensure it is accessible to all, and repair the damage inflicted by the pandemic on women’s healthcare services more generally. Clea Harmer, the chief executive of bereavement charity Sands, said improving maternity safety also needs to be at the top of the UK’s agenda. The government said it was committed to ensuring all women received safe and compassionate care from maternity services, regardless of their ethnicity, location or economic status. Anneliese Dodds, the shadow women and equalities secretary, said Labour would seek to reverse the “deeply concerning” maternal mortality figures by training thousands more midwives and health visitors and incentivising continuity of care for women during pregnancy. Read full story Source: The Guardian, 11 January 2024
  22. News Article
    A British mother-of-three has died just days after undergoing a Brazilian bum-lift operation in Turkey. Demi Agoglia, 26, of Salford, Greater Manchester, died from a heart attack caused by the operation just hours before she was due to return to Manchester from Istanbul where she had the operation, her family said. Ms Agoglia, who had a seven-month-old baby boy, went back to the clinic in Istanbul for a check-up but had a heart attack in a taxi on the way to the hospital as her partner, Bradley Jones, gave her CPR in a desperate bid to save her life. Her brother Carl, 37, said Ms Agoglia’s family and partner had tried to convince her not to go through with the bum-lift as they were concerned for her safety. Last year, a British surgeon warned of the dangers faced by Brits who fly to countries like Turkey for cheaper cosmetic surgery. “Many people fail to do their research and focus too much on money, rather than the quality or safety of the clinic,” Dr Ahmed Alsayed, who is lead surgeon and medical director at plastic surgery specialists Signature Clinic told HullLive. “Clinics in the UK have to adhere to the strictest levels of expertise, safety and cleanliness. You just can’t be sure you’ll get that from a cheaper option abroad,” Dr Alsayed said. Read full story Source: The Independent, 10 January 2023
  23. News Article
    The UK has some of the worst cancer survival rates in the developed world, according to new research. Analysis of international data by the Less Survivable Cancers Taskforce found that five-year survival rates for lung, liver, brain, oesophageal, pancreatic and stomach cancers in the UK are worse than in most comparable countries. On average, just 16% of UK patients live for five years with these cancers. Out of 33 countries of comparable wealth and income levels, the UK ranks as low as 28th for five-year survival of both stomach and lung cancer, 26th for pancreatic cancer, 25th for brain cancer and 21st and 16th for liver and oesophageal cancers respectively. The six cancers account for nearly half of all common cancer deaths in the UK and more than 90,000 people are diagnosed with one of them in Britain every year. The taskforce calculated that if people with these cancers in the UK had the same prognosis as patients living in countries with the highest five-year survival rates – Korea, Belgium, the US, Australia and China – then more than 8,000 lives could be saved a year. Anna Jewell, the chair of the Less Survivable Cancers Taskforce, said: “People diagnosed with a less survivable cancer are already fighting against the odds for survival. If we could bring the survivability of these cancers on level with the best-performing countries in the world then we could give valuable years to thousands of patients. “If we’re going to see positive and meaningful change then all of the UK governments must commit to proactively investing in research and putting processes in place so we can speed up diagnosis and improve treatment options.” Read full story Source: The Guardian, 11 January 2023
  24. Content Article
    MBRRACE have released their latest UK maternal mortality figures. The maternal death rate in 2020-22 was 13.41 per 100,000 maternities. This is significantly 53% higher than the rate of 8.79 deaths per 100,000 maternities in the previous three year period (2017-19).
  25. Content Article
    A story of a bereaved mother’s experience with the Coroner's Service in the aftermath of her previously well 25-year-old daughter Gaia’s unexpected and unexplained death and why she set up TruthForGaia.com in her search for the truth.  This case demonstrates systemic failings in the Coroner Service: the dismissive way that bereaved family members are treated through the inquest process and a lack of clinical curiosity to determine the primary cause of death.  This inconclusive inquest prompts wider questions about who speaks up for the dead. Just as we have Martha’s rule in life, should there be a Gaia’s rule in death to help families be heard about failed inquests? Gaia’s death and failed inquest are chilling reminders that this could happen to any one of us and our families.
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