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Showing results for tags 'Patient death'.
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Content Article
Sorry needn’t be the hardest word
Patient Safety Learning posted an article in Complaints
Nick Wright co-founder of the Apology Clause campaign wrote an article on why organisations need to say sorry The law supports apologies. The Compensation Act 2006 says “an apology, an offer of treatment or another redress, shall not itself amount to an admission of negligence or breach of statutory duty”. However, too many organisations put their fear of legal ramifications over what they see as their moral obligations. They fear if they apologise properly they will leave themselves open to legal action. That refusal to do the right thing can have serious and lasting impact on victims. A clear apology can lift the burden that victims very often carry for a long time after a trauma. It can enable them to move on. To stop blaming themselves. To stop re-living the most agonising moment. To rebuild. -
Content Article
UK Covid-19 Inquiry website
Patient Safety Learning posted an article in Covid-19 Inquiry
The UK Covid-19 Inquiry has been set up to examine the UK’s response to and impact of the Covid-19 pandemic, and learn lessons for the future. The Inquiry’s work is guided by its Terms of Reference. -
Content ArticleThe aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital. This Healthcare Safety Investigation Branch (HSIB) report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment.
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Content ArticleThis Healthcare and Safety Investigation Branch (HSIB) report explores the under recognised toxicity of propranolol in overdose. Propranolol is used to treat a number of medical conditions, including migraine, cardiovascular problems and the physical effects of anxiety. The case that prompted the investigation was Emma, a 24-year old woman, took an overdose of both propranolol and citalopram (an antidepressant). She called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died. There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. Between 2012 and 2017 there was a 33% increase in the number of deaths reported as being linked to propranolol overdose, with 52 deaths recorded as having been linked to propranolol overdose in 2017.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) carried out a themed review of their maternal death investigations during the coronavirus (COVID-19) pandemic. The national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety. Explore wider patient safety processes.
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Content ArticleIn March 2020, the Healthcare Safety Investigation Branch (HSIB) published a national learning report to highlight the themes emerging from the initial investigations carried out as part of their maternity investigation programme. These initial investigations were carried out between April 2018 and December 2019. One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia). This was identified as an area where further analysis could benefit system-wide learning.
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Content Article
Martha Mills died from sepsis aged 13 after sustaining a pancreatic injury from a bike accident. The inquest into her death heard that she would likely have survived had consultants made a decision to move her to intensive care sooner. Her mother, Merope, has spoken about the failures in Martha’s care, and how she trusted the clinicians against her own instincts – they didn’t listen to her concerns and instead “managed” her. This report is a response to that call from Martha Mills’ parents to rebalance the power between patients and medics with one purpose only: to improve patient safety. It comes amidst significant evidence that shows that failing to properly listen to patients and their families contributes to safety problems in the NHS. -
Content ArticleThis report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal.
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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Content ArticleSamantha Gould was 16 years old when she died by suicide due to an overdose of prescribed medication on 2 September 2018. She had borderline personality disorder that meant she was at risk of deliberate self-harm and suicide. In this report, the Coroner highlights concerns about a systemic weakness in the way in which Child and Adolescent Mental Health Services and primary care communicate with local pharmacies concerning 16-18 year old patients who are at risk of deliberate overdose. In spite of a safety plan agreed with Sam’s consultant psychiatrist whereby Sam’s parents would be responsible for her medication, Sam was able to pick up older prescriptions on 1 September 2018 without challenge, and it was those medications that were fatal in the combined amounts ingested by Sam.
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Content ArticleThe information that care homes submit to CQC about the deaths of people in their care is published on a weekly basis as part of the Office for National Statistics (ONS) reporting on deaths. The ONS data is not broken down by whether the person who died had a disability. Supported by ONS, the Care Quality Commission (CQC) has completed a targeted piece of analysis to better understand the impact of coronavirus (COVID-19) on people with a learning disability, some of whom may also be autistic, and how the number of deaths during this period compares to the number of deaths last year. This analysis looked at all deaths notified to CQC between 10 April and 15 May from providers registered with CQC who provide care to people with a learning disability and/or autism (including providers of adult social care, independent hospitals and in the community), and where the person who died was indicated to have a learning disability on the death notification form.
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Content Article
Our son’s final days
Claire Cox posted an article in Patient stories
NHS investigators are to meet the family of a young, autistic man - left starving and desperately thirsty in hospital while waiting for a delayed operation. Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. These are the harrowing events that came days before the needless, avoidable death of Mark Stuart. Mark was a young man with autism. -
Content Article
The Lampard Inquiry
Mark Hughes posted an article in Inquiries
The Lampard Inquiry is a statutory inquiry investigating mental health inpatient deaths in Essex, focused on services provided by the Essex Partnership University Foundation NHS Trust (EPUT) and the North East London Foundation Trust (NELFT) and their predecessor organisations. This Inquiry continues the work of the Essex Mental Health Independent Inquiry. This website provides information about the inquiry team, terms of reference and publications relating to this. -
Content ArticleFollowing Jeremy Hunt’s appointment as chancellor, HSJ is now hosting the Patient Safety Watch newsletter, written by Patient Safety Watch trustee James Titcombe. Read the latest newsletter: Patient Safety Watch: What can be done to improve duty of candour?
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the use of oral morphine sulfate solution (a strong pain-relieving medication taken by mouth). As its ‘reference case’, the investigation used the case of Len, an 89 year-old man who took an accidental overdose of morphine sulfate oral liquid. Patient Safety Learning has published a blog reflecting on the key patient safety issues highlighted in this report.
