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Showing results for tags 'Patient death'.
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News Article
UK has some of worst cancer survival rates in developed world
Patient Safety Learning posted a news article in News
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 -
Content Article
MBRRACE-UK: Maternal mortality 2020-2022
Patient Safety Learning posted an article in Maternity
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). -
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. -
News ArticleThe family of an autistic teenager who died from an accidental overdose say they had to investigate the death themselves to find the truth of how he died. Will Melbourne, 19, was found dead at his Cheshire home on December 18, 2020 after he mistakenly had taken a strong synthetic opioid 100 times stronger than morphine he bought on the dark web. The inquest into Will's death took three years to come back and his family say had to investigate the matter themselves to find out what happened. Sally and John Melbourne said their lives were put on hold during the long wait for the inquest to be completed and the family were told at the pre-inquest hearing that the court were short-staff and had a backlog of 500 cases. Parents and friends of the teenager used a trail of digital "breadcrumbs" to uncover that Will had tried to buy oxycodone, a highly addictive opioid that helps with pain relief and anxiety, which turned out to be a synthetic opioid. The blue pills Will had bought on the darknet were found beside his body. The family say the drugs were not tested until they raised it with the coroner's court a year after his death. Will's blood sample had also been destroyed after the company storing it went into administration. The family said they were left traumatised by the time the inquest was concluded. Mrs Melbourne said: "We thought the inquest system was there to give us answers. Instead, we felt blocked at every turn. "It was outrageous that we had to take the investigation on ourselves." Read full story Source: Mail Online, 4 January 2023
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Content ArticleDerek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. In a blog published on the Making Families Count website, Derek explores some aspects of how the family's complaints were handled. Further reading on the hub: “Getting the hospital to be honest with us felt like a battle from day one.” An interview with Derek Richford
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News ArticleIn 2016, Kettering General Hospital (KGH) became the focus of a major criminal inquiry. Documents seen by the BBC reveal detectives looked for evidence of gross negligence manslaughter over the treatment of Jorgie Stanton-Watts, a vulnerable toddler. Seven years of investigations followed, by the hospital, regulators and a coroner. The family has struggled to hold people to account. Since Jorgie's death, a BBC investigation has heard from more than 50 parents with serious concerns about the treatment of their children, many of whom died or suffered injury. The Northamptonshire hospital has also been inspected regularly. In April the Care Quality Commission (CQC) downgraded the hospital's children's services to inadequate, the lowest possible rating. Read full story Source: BBC News, 10 January 2024
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News Article
Letby inquiry: Former nurse director among ‘core participants’
Patient Safety Learning posted a news article in News
The former nursing director at the hospital where Lucy Letby murdered seven babies will be among the 'core participants' of the Thirlwall Inquiry. The inquiry, chaired by Lady Justice Thirlwall, will investigate how Letby was able to commit the murders and attempt six others while she worked as a neonatal nurse at Countess of Chester Hospital NHS Foundation Trust in 2015 and 2016. This week, Alison Kelly, who was director of nursing and quality at the trust during the time of Letby's crimes, was announced as 1 of 10 core participants in the inquiry. Also named were former Countess of Chester chief executive Tony Chambers, former medical director Ian Harvey and former human resources director Sue Hodkinson. Ms Kelly and Mr Harvey were among the senior staff at the trust who were accused of failing to act when clinicians first raised concerns about Letby. How managers responded to such concerns is one of the areas due to be investigated by the Thirlwall Inquiry. A number of organisations are also on the list as core participants, including the Nursing and Midwifery Council (NMC), NHS England, the Royal College of Paediatrics and Child Health, the Department of Health and Social Care and Countess of Chester itself. Read full story Source: Nursing Times, 3 January 2024 -
News Article
Essex coroner warns of more deaths due to lack of mental health care
Patient Safety Learning posted a news article in News
A coroner overseeing a teenager's inquest has warned there will be more deaths unless mental health services improve for autistic people at risk of self-harm. Morgan-Rose Hart, 18, who had ADHD, autism and a history of mental illness had been a patient at a unit in Harlow, Essex, for three weeks. An inquest jury concluded she died by misadventure contributed to by neglect. Ms Hart, from Chelmsford, died in hospital six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow, Essex in July 2022. The inquest into her death heard staff observations were falsified and critical observations were missed. In her Prevention of Future Deaths report, Ms Hayes said: "There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community." She added: "During the course of the inquest the evidence revealed matters giving rise to concern. "In my opinion, there is a risk that future deaths will occur unless action is taken." Read full story Source: BBC News, 8 January 2024 -
Content ArticleMorgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.
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Content ArticleAndrew Guillaume was admitted to Warwick Hospital on the 6 June 2023. Following a review, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team. However, no referral was made as the Consultant was unable to get through to the switchboard at UHCW, so Mr Guillaume remained at Warwick Hospital. Subsequently his condition worsened and on the 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite his surgery, but again they were unable to reach the team through the switchboard. Mr Guillaume was admitted to the unit on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.
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News Article
Prescription drugs sold online without robust checks
Patient Safety Learning posted a news article in News
Patients' lives are being put at risk because it is too easy to buy prescription-only medicines from online pharmacies, a leading pharmacist says. A BBC investigation found 20 online pharmacies selling restricted drugs without checks - such as GP approval. In total, over 1,600 various prescription-only pills were bought during the investigation entering false information without challenge. Regulator the General Pharmaceutical Council says extra checks are needed when selling some drugs online. The BBC's findings highlight the "wild west" of buying medicines on the web, says Thorrun Govind, a pharmacist, health lawyer and former chair of the Royal Pharmaceutical Society. "The current guidance basically tells pharmacies to be robust, but do that in your own way, and we know that under this current system, patients have died," she says. The parents of a woman who died in 2020, after accidentally overdosing on medicines she bought online, are among those calling for stricter rules. Katie Corrigan, from St Erth in Cornwall, had developed an addiction to painkillers after experiencing neck pain. "Katie needed help, she didn't need more medication," says her mum, Christine Taylor. Her GP had stopped supplying the drug after realising she had been allowed to request new prescriptions prematurely and been prescribed too much. Instead, Katie, 38, was able to buy a painkiller and a drug used to treat anxiety from multiple online pharmacies without notifying her GP. The coroner at Katie's inquest confirmed her GP had not been contacted by any of the pharmacies to check the drug was safe for her. In his final report, he said the safety controls were inadequate. Read full story Source: BBC News, 5 January 2024 -
News ArticleAt least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
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Content ArticleThis observational cross-sectional study in the American Journal of Surgery aimed to quantify the association between US state trauma funding and both in-hospital mortality and transfers of injured patients. The authors concluded that Increased state trauma funding is associated with decreased adjusted in-hospital mortality and fewer interfacility transfers to a second acute care hospital.
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News Article
Baby died of neglect after staff turned off emergency alarm, coroner rules
Patient Safety Learning posted a news article in News
Hospital neglect contributed to the death of a two month old baby after staff turned off emergency alarms, a coroner has ruled. Louella Sheridan died at Royal Bolton Hospital in on 24 April 2022 after she was admitted with bronchiolitis to the hospital’s intensive care unit before later dying from Covid and a related heart condition. Four alarms on a monitoring machine were silenced and then switched off before the baby collapsed in a high dependency unit, it has been found. On Wednesday coroner John Pollard ruled neglect by staff had contributed to Louella’s death after staff switched off the alarms on the monitors attached to her during the night. Summing up his conclusion Coroner Pollard reportedly said there was a “gross failure “ to provide basic medical care to Louell and that had care been given, had the alarms been switched on to alert staff her life may have been extended at least for a short period of time. He said turning off the alarms was a gross type of conduct. Read full story Source: The Independent, 22 December 2023 -
Content ArticleThe National Child Mortality Database (NCMD) has published its latest Thematic Report. Based on data from April 2019 to March 2022, this report includes child deaths where infection may have contributed to the death and those where infection provided a complete and sufficient explanation of death. The Thematic Report covers: variations in incidence of child deaths with infection infection related deaths characteristics of children who died where infection may have contributed or caused the death and where infection provided a complete and sufficient explanation of death details of the infections and their clinical presentations. It also includes learning from Child Death Overview Panel (CDOP) completed child death reviews where death was categorised as infection, as well as next steps.
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Content ArticleIn this article for the Byline Times, Saba Salman highlights the results of the latest NHS-funded annual review of deaths among people with learning disabilities. The report lays bare how people with learning disabilities are less likely to survive health problems that are preventable and treatable than those without learning disabilities. Researchers at King’s College London, the University of Central Lancashire and Kingston University London reviewed the deaths of 3,648 people with a learning disability. Overall, almost half died an avoidable death, compared to two in 10 in the general population. The median age of death in was 63 years, which is around 20 years less than for people without learning disabilities.
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Content ArticleIn this article, NHS England reports on progress in achieving the aims of the National patient safety strategy which was released in 2019: saving an additional 1,000 lives and £100 million per year. The article suggests that in 2023, the NHS is halfway to reaching this target and shares the following highlights: The National Patient Safety team, supported by staff across the NHS identifying and recording patient safety incidents, continues to save an estimated 160 lives per year through mitigation of risk. This is also estimated to reduce disability due to severe harm incidents by around 480 cases per year and to save £13.5 million in additional treatment costs. Since the strategy was launched, an estimated 291 fewer cases of cerebral palsy have occurred since September 2019 due to the administration of magnesium sulphate during pre-term labour as part of the PReCePT programme, supported by the Patient Safety Collaboratives. This has saved up to £291 million in lifetime care costs, assuming £1 million per case. Work supported by the Maternity and Neonatal Safety Improvement Programme to ensure optimal cord management during labour has saved up to 465 lives since 2020. We estimate 414 fewer deaths and 2,569 fewer cases of moderate harm due to long term opioids following the work of our Medication Safety Improvement Programme since November 2021. The Medication Safety Improvement programme has also led to: 420 fewer admissions for major bleeds per year from anticoagulants and non-steroidal anti-inflammatory drugs (NSAIDs), 1,979 fewer cases of drug induced acute kidney injury, 104 fewer asthma/COPD admissions due to sub-optimal inhaler prescribing, 1,000 fewer patients at risk of methotrexate overdose and 16,920 hospital readmissions avoided by Discharge Medicines Service. It is estimated this has released over £7 million in admissions costs. Early adopters of the Patient Safety Incident Response Framework (PSIRF) are reporting improved safety cultures, identification of more effective risk reduction strategies and early signs of harm reduction, due to their revised approach. It is estimated that there are 36 fewer gas misconnection events every year, each one representing a potential death or severe harm event, due to a focus on reducing risks through the Never Events Framework and National Patient Safety Alerts (NPSAs). 11,621 care homes have been engaged on work to improve management of patient deterioration. This leads to reduced 999 calls, fewer emergency admissions and shorter lengths of stay. 38 mental health wards piloting work on restraint, seclusion and rapid tranquilisation have seen a 15% reduction in those practices.
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Content ArticleOn 11 January 2021 an investigation into the death of Susan Ann Gladstone was started. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was Susan died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood: 1a Intraparenchymal and subarachnoid haemorrhage.
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News ArticleNHS England has been told it must take action to raise awareness about the potentially fatal interaction between tramadol and warfarin, following the death of a patient. Graham Danbury, assistant coroner for Hertfordshire, issued a prevention of future deaths report on 1 December 2023, after Susan Gladstone, from Hertfordshire, died on 8 January 2021 from a bleed in the brain. An inquest, which ended on 20 November 2023, concluded that Gladstone “died as a result of a generally unknown interaction between warfarin and tramadol, which caused exceptional thinning of her blood”. Gladstone was prescribed tramadol twice for lower back pain: on 20 December 2020 and 4 January 2021. According to the report, she had been taking the anticoagulation medication warfarin for “a number of years”. The report continues: “There was nothing to warn the prescribing doctor of any possible interaction. I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event, fatal INR to develop. “In my opinion, actions should be taken to prevent future deaths and I believe you, NHS England, have the power to take such action.” Read full story Source: Pharmaceutical Journal, 13 December 2023
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News Article
IT failures causing patient deaths, says NHS safety body
Patient Safety Learning posted a news article in News
Urgent action is needed to address NHS computer failings which are causing harm to patients, the patient safety watchdog has told BBC News. The watchdog has evidence of patient deaths due to IT system errors. The government called the reports "concerning" and said it would work with NHS England to take necessary action to protect patients. A recent investigation found thousands of hospital letters were unsent due to computer issues. The Health Services Safety Investigations Body (HSSIB) says IT failures are among the most serious issues facing hospitals in England. "We have seen evidence of patient deaths as a result of IT systems not working," said interim head, Dr Rosie Benneyworth. Dr Benneyworth cited the example of a patient who was found unresponsive and then wrongly identified by healthcare staff as not wishing to be resuscitated. Staff were unable to access information on the patient quickly through their IT system, which would have shown a mistake had been made, said the watchdog. Read full story Source: BBC News, 16 December 2023 -
News ArticleHundreds more middle-aged adults have been dying each month since the end of the pandemic, as obesity and NHS backlogs drive a surge in excess deaths. New analysis of official statistics has revealed that there were an extra 28,000 deaths in the UK during the first six months of 2023, compared with levels in the previous five years. The biggest rise in unexpected deaths has been among adults aged 50 to 64, who are increasingly dying prematurely from preventable conditions including heart disease and diabetes. The Covid inquiry is now being urged to shift its focus from “tactical decisions made by politicians” and to examine the lasting disruption that has kept deaths persistently high since the virus peaked. Experts believe that difficulties in accessing GPs since lockdown and record NHS waiting lists mean that middle-aged patients are missing out on life-saving preventative treatment such as blood pressure medication. Unhealthy lifestyles, obesity and widening health inequalities are also contributing to a rise in avoidable deaths. Professor Yvonne Doyle, who led Public Health England during the pandemic, warned that the official Covid inquiry risks “missing the point” by focusing on the drama and WhatsApps of Westminster politicians. In an article for The Times, Doyle, who gave evidence to the inquiry six weeks ago, says that the tens of thousands of excess deaths since Covid “represent an underlying pandemic of ill health” that should be addressed. Read full story (paywalled) Source: The Times, 13 December 2023
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News ArticleA fresh inquest into the death of Raychel Ferguson has found she died of a cerebral oedema, or swelling in the brain, due to hyponatraemia. He said the "inappropriate infusion of hypertonic saline fluid" was the most significant factor. The nine-year-old died at the Royal Victoria Hospital for Sick Children in June 2001. Coroner Joe McCrisken said her death was due to a series of human errors and not systemic failure. He outlined three causes of the hyponatraemia but said he was satisfied the "inappropriate infusion of hypertonic saline fluid... played the most significant part". The new inquest into Raychel's death was first opened in January 2022 after being ordered by the attorney general but was postponed in October when new evidence came to light. Raychel was one of five children whose deaths over the course of eight years at the same hospital prompted a public inquiry. In 2018 the Hyponatraemia Inquiry - which examined the deaths of five children in Northern Ireland hospitals, including Raychel - found her death was avoidable. The 14-year-long inquiry was heavily critical of the "self-regulating and unmonitored" health service. In his report in 2018, Mr Justice O'Hara found there was a "reluctance among clinicians to openly acknowledge failings" in Raychel's death. Read full story Source: BBC News, 11 December 2023
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Content ArticleIn this video and accompanying transcript, clinical decision support researcher F Perry Wilson looks at the importance of health records and databases indicating whether or not a patient is deceased. If they are not up to date and sharing this information with the right staff and processes, inappropriate messages can be sent to healthcare professionals or the deceased patient's family. He argues that as well as being a waste of resources, sending communications requesting procedures or offering appointments in this situation undermines confidence and trust in health systems, in both staff and members of the public.
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News ArticleThe risk of dying from cancer in England “varies massively” depending on where a person lives, according to a study that experts say exposes “astounding” health inequalities. Researchers who analysed data spanning two decades found staggering geographical differences. In the poorest areas, the risk of dying from cancer was more than 70% higher than the wealthiest areas. Overall, the likelihood of dying from cancer has fallen significantly over the last 20 years thanks to greater awareness of signs and symptoms, and better access to treatment and care. The proportion dying from cancer before the age of 80 between 2002 and 2019 fell from one in six women to one in eight, and from one in five men to one in six. However, some regions enjoyed a much larger decline in risk than others, and the new analysis has revealed that alarming gaps in outcomes remain. “Although our study brings the good news that the overall risk of dying from cancer has decreased across all English districts in the last 20 years, it also highlights the astounding inequality in cancer deaths in different districts around England,” said Prof Majid Ezzati, from Imperial College London, who is a senior author of the study. Read full story Source: The Guardian, 11 December 2023
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Content ArticleCancers are the leading cause of death in England. This study from Rashid et al. published in Lancet Oncology aimed to estimate trends in mortality from leading cancers from 2002 to 2019 for the 314 districts in England. The study found that declines in overall cancer mortality have been unequal both geographically and among different groups of cancers. The greatest geographical inequality was observed for cancers with modifiable risk factors and potential for screening for precancerous lesions. Addressing risk factors such as smoking and alcohol use, expanding access to and utilisation of screening for prevention and early detection, and improving the quality of care should be used to reduce deaths in areas where they remain highest. High-resolution spatiotemporal data can help identify where intervention is required and track progress.
