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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.
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News Article
Calls for police to investigate mental health deaths in Norfolk and Suffolk
Patient Safety Learning posted a news article in News
Campaigners have written to the chief constables of Norfolk and Suffolk to request an investigation into thousands of mental health deaths in those areas. They say coroners are raising safety issues but no improvements are being made. A report by independent auditors found as many as 8,440 patients had died unexpectedly over three years. Norfolk and Suffolk NHS Foundation Trust said it had started a review of patient deaths. Coroners worried about the risk of future deaths highlight unsafe practices in prevention of future deaths reports (PFDs). And authorities are required by law to respond with an action plan within 56 days. The Norfolk and Suffolk trust said it had responded to all PFDs and was working to ensure recommendations and actions were implemented. But Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "There's a criminal case to answer. And we want the police to investigate, where the same mistakes have been repeated time and time again." He said coroners were repeatedly warning of risks such as delays to treatment, lack of patient follow-ups, chaotic record keeping and disorganised communication between teams. Mr Harrison said: "The mental health trust always responds saying they've learned lessons, they are changing policy and practices. "But then what we're seeing in analysing the orders from the coroner are repeat circumstances where other people have died in similar circumstances to a previous prevention-of-future-deaths notice." Read full story Source: BBC News, 12 December 2023 -
Content ArticleMartha Mills was 13 when she tragically died due to a series of medical errors. In this video by the Patient Safety Movement Foundation (PSMF), Martha's mother Merope Mills tells her story and aims to raise awareness about the consequences of medical errors. Merope advocates for improved patient safety measures including the introduction of Martha's Rule, which will allow patients and their families to trigger an urgent clinical review from a different team if they are in hospital, are deteriorating rapidly and feel they are not getting the care they need.
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News Article
CQC sorry for failing to act on ‘note tampering’ concerns
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has apologised after admitting it failed to act on whistleblowing concerns “in a timely manner”. Allegations had been made to the CQC about staff at Cambridgeshire and Peterborough Foundation Trust tampering with a patient’s record after they had died by suicide. As previously reported, the accusations by whistleblower Des McVey have sparked a review of the trust’s conduct in more than 60 suicide cases. Mr McVey says the trust only took action following media coverage and that the CQC had ignored his concerns. The regulator has now upheld a complaint from him, with operations manager James DeCothi writing to Mr McVey: “I have established that [the relevant CQC inspector] did not share your concerns with the provider in a timely manner and that our contact with you from July 2022 to June 2023 was inconsistent. I apologise on behalf of CQC for this. [The CQC inspector] has reflected on this and has asked me to offer her apologies to you also. “I can confirm that CQC have followed up the areas of concern that you have shared, and we will continue to use the information you have shared to inform future regulatory activity. I would like to thank you again for sharing this information with us.” Read full story (paywalled) Source: HSJ, 11 December 2023 -
Content ArticleIn this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
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Content ArticleMr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15 June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24 June he was noted to have suffered a significant deterioration – with symptoms of thought disorder, anxiety, and responding to hallucinations – and following a mental health act assessment on 28 June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1 July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2 July. His room at supported accommodation was entered on 3 July and he was found deceased. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was: 1a Cervical spinal cord injury. 1b Laceration. The conclusion of the inquest was that death was the consequence of suicide.
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Content ArticlePeter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3 August 2022 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On the 14 October he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He then contacted services further a number of times. On 10 November 2022 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.
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Content Article
The 2022 LeDeR report seeks to investigate and learn from the avoidable deaths of people with a learning disability in England. The report, which is produced for NHS England, was led by researchers from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London, the University of Central Lancashire, and Kingston University London. Researchers found: gentle but continuous improvement in the median age of death for people with a learning disability in 2022. In 2018, the median age of death for adults with a learning disability was 61.8 years but has since risen to 62.9 in 2022. If children are included, the age at death increased from 60.1 years in 2018 to 62.7 in 2022. a drop in the number of avoidable deaths since 2021 – 42% of deaths were deemed “avoidable” for people with a learning disability in 2022 compared to 50% in 2021. a sharp drop in the number of deaths due to Covid-19 – from 24% of all causes of death in 2020 to 19% in 2021 and 6% in 2022 for adults with a learning disability. "While there are positives, it’s also clear that more work still needs to be done. People from ethnic minority groups died younger, and there is a need to improve access to care pathways to improve prevention and better manage some conditions in people with a learning disability, such as cancer, lung, heart and circulatory conditions. We also identified a concerning effect on excess deaths of people with a learning disability during heatwaves. This means care homes and hospitals looking after people with a learning disability need to be better prepared for weather events in the light of climate change. Improvements during 2022 should certainly be celebrated, but we shouldn’t overlook how much we still don’t know." Professor Andre Strydom, Chief Investigator and Professor in Intellectual Disabilities at King’s IoPPN. Read the full report via the link below. -
Event
Investigation and Learning From Deaths
Patient Safety Learning posted an event in Community Calendar
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. By 2024, all deaths in the community or acute settings that do not required to be referred to the coroner (non-coronial deaths) will need to be scrutinised by a medical examiner. 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 frida@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningFromDeaths -
News Article
Health secretary told to intervene over ‘systemic’ ambulance deaths
Patient Safety Learning posted a news article in News
Ministers must intervene over systemic failures which are “too big for hospital or ambulance trusts to fix on their own” and have led to multiple preventable deaths, a senior coroner has warned. In a move usually considered rare for such an official, Cornwall and Isles of Scilly coroner Andrew Cox has written to the Department of Health and Social Care a second time over ongoing delays to ambulance responses and long ambulance handovers in the area. Last year he warned the NHS was “broken” after he ruled ambulance and emergency care delays contributed to the deaths of four people. Now, he has sent a similar report on the same types of failings in the deaths of John Seagrove, Pauline Humphris, and Patricia Steggles at Royal Cornwall Hospital to new health secretary Victoria Atkins. Mr Cox wrote: “I set out in my [prevention of future death report] last year my understanding of the reasons for the difficulties that are continuing in the Cornwall & Isles of Scilly coroner area. I do not believe those reasons will have changed significantly. ”The challenges are systemic in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for either the hospital trust or the ambulance trust to fix on their own.” Read full story Source: HSJ, 1 December 2023 -
Content ArticleThe helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries, and another was seriously injured. The investigation carried out by the Air Accidents Investigation Branch identified the following causal factors: The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the DH HLS. Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around the DH HLS that was subject to high levels of downwash. Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the HLS Site Keepers, and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.
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Content ArticleThe first 14 minutes of this programme are focused on a Newsnight investigation into allegations of cover-up, avoidable harm and patient deaths relating to University Hospitals Sussex NHS Foundation Trust. At the time of broadcast, Sussex Police were investigating 105 claims of alleged medical negligence at the Trust.
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News Article
Parents 'destroyed' after baby's death at Royal Sussex County Hospital
Patient Safety Learning posted a news article in News
Parents of a two-day-old girl who died in hospital after an emergency C-section are calling for a national inquiry into maternity services. Abigail Fowler Miller died at Brighton's Royal Sussex County Hospital (RSCH), in January last year. On 21 January 2022, Mr Miller and Katie Fowler contacted the hospital's maternity assessment unit four times during the day. Their first phone call was to inform the maternity assessment unit Ms Fowler was in labour, then to report bleeding, and finally to tell them she had become faint and short of breath. According to the Health Safety Investigation Branch's (HSIB) report, staff recorded that Ms Fowler sounded "distressed" in the fourth phone call to the unit, and she thought she was having a panic attack. Staff said she could not answer questions in the fourth phone call because of her "distressed state" and she was asked to come into the hospital. Ms Fowler went into cardiac arrest on the journey in a taxi due to a uterine rupture. An inquest last week found her life would have been prolonged if her mother had been admitted to hospital sooner. In October, families whose babies have died or been harmed in the care of the NHS called for a statutory public inquiry into England's maternity services. Robert Miller, Abigail's father, told BBC Newsnight: "A national inquiry is the only way forward - we cannot continue to treat every incident as a separate tragedy." Read full story Source: BBC News, 28 November 2023 -
News Article
At least 20,000 annual UK cancer deaths avoidable, says charity
Patient Safety Learning posted a news article in News
At least 20,000 cancer deaths a year could be avoided in the UK with a national commitment to invest in research and innovation, and fix the NHS, says Cancer Research UK. Progress is being made in finding new treatments for the condition that affects 50% of people at some point. But the charity says the UK lags behind comparable countries for survival. It has launched a manifesto of priorities for this government and the next, ahead of a general election. The document sets out what the charity says needs to change - and fast. Whoever is running the country must commit to developing a 10-year cancer plan, spearheaded by a National Cancer Council accountable to the prime minister to bring government, charities, industry and scientific experts together, it says. Key areas to focus on include: More investment in research to close an estimated £1bn funding gap. Greater disease prevention - banishing smoking to the history books, for example. Earlier diagnosis, through screening. Better tests and treatments, as well as cutting NHS waiting lists and investing in more staff. Read full story Source: BBC News, 28 November 2023 -
News ArticleA patients group representing several British victims has launched legal action against the Spanish government over claims it failed to safeguard people against the potentially fatal side effects of one of the country’s most popular painkillers, involved in a series of serious illnesses and deaths. The drug metamizole, commonly sold in Spain under the brand name Nolotil, is banned in several countries, including Britain, the US, India and Australia. It can cause a condition known as agranulocytosis, which reduces white blood cells, increasing the risk of potentially fatal infection. The Association of Drug Affected Patients (ADAF) says adverse reactions to the drugs have led to sepsis, organ failure and amputations. It has identified about 350 suspected cases of agranulocytosis between 1996 and 2023, including those of 170 Britons who live in Spain or were on holiday there. The ADAF is examining more than 40 fatalities in which it considers the drug may have led, or contributed, to death. The patients group says that case reports, including a 2009 study, suggest the British population may be more susceptible to the drug’s side effects, but this has not been confirmed by independent scientific study. The group is demanding an investigation into the drug and new controls. It filed its action on 14 November in the national court in Madrid. Cristina García del Campo, founder of the organisation, said: “This drug has destroyed people’s lives and it should now be withdrawn. One lady took three tablets and she had part of her feet amputated and several fingers. Even if it doesn’t kill you, once you’ve had sepsis your body is never the same.” Read full story Source: The Guardian, 26 November 2023
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Content ArticleSepsis, characterised by significant morbidity and mortality, is intricately linked to socioeconomic disparities and pre-admission clinical histories. This study in eClinical Medicine looked at the association between non-COVID-19 related sepsis and health inequality risk factors amidst the pandemic in England, with a secondary focus on their association with 30-day sepsis mortality. It found that socioeconomic deprivation, comorbidity and learning disabilities were associated with an increased odds of developing non-COVID-19 related sepsis and 30-day mortality in England. This study highlights the need to improve the prevention of sepsis, including more precise targeting of antimicrobials to higher-risk patients. It also revealed that people with learning disabilities were almost four times as likely to develop the life-threatening illness. People with chronic liver disease were just over three times as likely, and chronic kidney disease stage 5 over 6 times more likely to develop non-COVID-19 sepsis. Cancer, neurological disease, immunosuppressive conditions, and having multiple prior courses of antibiotics were also associated with developing non-COVID-19 sepsis.
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News Article
NHS care delays in England harmed 8,000 people and caused 112 deaths last year
Patient Safety Learning posted a news article in News
Almost 8,000 people were harmed and 112 died last year as a direct result of enduring long waits for an ambulance or surgery, prompting warnings that NHS care delays are “a disaster”. The fatalities included a man who died of a cardiac arrest after waiting 18 minutes for his 999 call to be answered by the ambulance service and was dead by the time the crew arrived. The figures are the first time NHS England has disclosed how often doctors and nurses file a patient safety report after someone suffers harm while waiting for help. They show that patient deaths arising directly from care delays have risen more than fivefold over the last three years, from 21 in 2019 to 112 last year, as the NHS has come under huge strain. The number of people who came to “severe harm” has also jumped from 96 to 152 during that period. “These data are alarming and show quite clearly the human impact the crisis in the NHS is having on individual patients,” said Rachel Power, the chief executive of the Patients Association. “We have been watching a disaster unfolding across the NHS and have repeatedly warned about the threat to patient safety because of it.” Read full story Source: The Guardian, 27 November 2023 -
News Article
Coeliac UK calls for change following death of coeliac patient in hospital
Patient Safety Learning posted a news article in News
A North Wales coroner has concluded there was a ‘gross failure’ in the case of a coeliac patient, who tragically died in Wrexham Maelor hospital. Mrs Hazel Pearson, 79, had coeliac disease and a number of other medical conditions and died from aspiration pneumonia four days after being given Weetabix for breakfast while at the hospital. Whilst her coeliac disease was noted on her admission records, there was no sign above her bed and staff were unaware of her dietary needs and as a result Mrs Pearson had been fed gluten containing food on multiple occasions. Tristan Humphreys, Head of Advocacy for Coeliac UK said: “We are deeply saddened and concerned by this verdict and our thoughts go out to Mrs Pearson’s loved ones at this very difficult time. Her death reflects a clear failure of care and it is patently unacceptable that this was allowed to happen. Coeliac disease is a serious autoimmune condition for which the only treatment is a medically prescribed gluten free diet. It is critical that people with coeliac disease can access the gluten free food they need to be healthy. This is all the more important when someone is unwell and, as in Mrs Pearson’s tragic case, unable to advocate for themselves. Wales has mandatory food standards which make very clear the level of care that should be provided yet these have not been met. As a charity, we are empowering patients, family members, carers and working with hospital caterers by providing advice and guidance to support safe provision of gluten free food. However, it’s high time the health service consistently delivered the care people with coeliac disease deserve.” Read full story Source: Coeliac UK, 24 November 2023 -
News Article
Poor people much more likely to die from sepsis, study finds
Patient Safety Learning posted a news article in News
Poor people and those with existing health problems are much more likely to die from sepsis, one of the UK’s biggest killers, a study has found. Sepsis, or blood poisoning, is a potentially fatal condition triggered when the body reacts to an infection by attacking its own tissues and vital organs. It leads to an estimated 48,000 deaths a year in Britain. Research from the University of Manchester has disclosed for the first time how some groups are at much higher risk of dying from the condition than the general population. An analysis of 248,767 cases of non-Covid sepsis in England between January 2019 and June 2022 has found that the most deprived people are twice as likely to die from it within 30 days. The findings, published in the journal eClinicalMedicine, also show that: People with learning disabilities are almost four times more likely to get sepsis. People with liver disease have about three times greater risk. Patients with chronic kidney disease that is at stage 5 are more than six times as likely to develop it. “This study shows socioeconomic deprivation, comorbidity and learning disabilities are associated with an increased risk of developing non-Covid related sepsis and 30-day mortality in England.” Read full story Source: The Guardian, 23 November 2023 -
News Article
Boy, 10, with asthma died due to ‘neglect by healthcare professionals’
Patient-Safety-Learning posted a news article in News
A 10-year-old boy with severe asthma died as a result of multiple failings by healthcare professionals amounting to neglect, a coroner has concluded. William Gray, from Southend, died on 29 May 2021 from a cardiac arrest caused by respiratory arrest, resulting from acute and severe asthma that was “chronically very under controlled”. His death has led to calls to improve asthma treatment for children nationwide. The court heard that William’s death was a “tragedy foretold” having previously suffered a nearly fatal asthma attack on 27 October, 2020, which he survived. The coroner said that William’s death was avoidable, his symptoms were treatable, and he should not have needed to use 16 reliever inhalers over 17 months, but instead his condition should have been treated with preventer medications and should have been controlled. Julie Struthers, a solicitor at Leigh Day who represented the family, said, “In an inquest involving concerns with medical treatment it is rare for a coroner to find neglect, and even rarer for a coroner to find Article 2, a person’s right to life, to be engaged. This reflects the real tragedy of what happened to William, the substantial number of failures by multiple healthcare professionals in his care, and the importance of improving asthma treatment for children nationwide.” Read full story (paywalled) Source: inews, 22 November 2023 -
Content Article
Thirlwall Inquiry
Mark Hughes posted an article in Other reports and inquiries
The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this.
