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News Article
Patient declared dead woke up in hospital
Patient Safety Learning posted a news article in News
An ambulance trust has apologised after a patient who was declared "dead" later woke up in hospital. As first reported by The Northern Echo, the individual was taken by paramedics to Darlington Memorial Hospital on Friday. The newspaper reported they had been declared dead following an incident earlier that day. The North East Ambulance Service (NEAS) apologised to the patient's family and said an inquiry had begun. The patient has not been identified or their current condition revealed. NEAS director of paramedicine Andrew Hodge said: "As soon as we were made aware of this incident, we opened an investigation and contacted the patient's family. "We are deeply sorry for the distress that this has caused them. "A full review of this incident is being undertaken and we are unable to comment any further at this stage. "The colleagues involved are being supported appropriately and we will not be commenting further about any individuals at this point." Read full story Source: BBC News, 17 October 2023 -
News Article
Why didn’t wife and mother get ‘miracle’ stroke treatment, grieving family ask
Patient Safety Learning posted a news article in News
A primary school teaching assistant died from a stroke after hospital staff told her family that the life-saving treatment she needed was not available at weekends. Jasbir Pahal, 44, who had four children and was known as Jas, died in November last year after suffering a stroke. Her family was told she could only be treated with aspirin because a procedure to remove the blood clot was only available from 8am to 3pm, Monday to Friday. It has now emerged that the life-saving treatment, called mechanical thrombectomy, was available at an NHS hospital trust just a 40-minute drive away from the Calderdale Royal hospital in Halifax where she was being treated, but there were no arrangements for such transfers. Jasbir’s husband, Satinder Pahal, 49, said: “We have paid the ultimate price for this deficient service. Despite our pleas to save Jas’s life, all they could do was to give her an aspirin. “My wife was a vegetarian, never drank alcohol or smoked. She was fit and healthy and she wasn’t given the chance to survive. Jas was the centre of our worlds and her loss will impact us for ever.” The family are calling for urgent action to prevent future deaths." The Observer reported last month of warnings by the Stroke Association charity and clinicians about the regional variations in access to mechanical thrombectomy. It has been described as a “miracle” treatment, with some patients who were at risk of death or permanent disability walking out of hospital the day after the procedure. Read full story Source: The Guardian, 15 October 2023 -
News Article
Jasper Brooks inquest: Baby died due to 'neglect' at hospital
Patient Safety Learning posted a news article in News
A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023 -
News Article
Sepsis killing too many as lessons not learned, warns NHS watchdog
Patient Safety Learning posted a news article in News
Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned. Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO). Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added. “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.” Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.” Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.” Read full story Source: The Guardian, 25 October 2023 Further reading on the hub: Top picks: Six resources about sepsis -
News ArticleA 25-year-old who died from a heart haemorrhage after being diagnosed with a panic attack had been seen by a non-medical school trained physician associate (PA) but not a doctor, it has emerged. Ben Peters, 25, attended the emergency department at Manchester Royal Infirmary on the morning of 11 Nov 2022 with chest pain, arm ache, a sore throat and shortness of breath. While waiting, he endured a “severe episode of vomiting”. Peters was diagnosed with a panic attack and gastric inflammation by the PA and sent home with two medications, after a supervising consultant, who the coroner found never reviewed the patient in person, agreed with the diagnosis. Less than 24 hours later, Peters died from a rare complication of the heart that had resulted in a tear of the heart’s major artery, known as aortic dissection, and led to a fatal haemorrhage. The Aortic Dissection Charitable Trust (TADCT) says around 2,000 people in Britain die from the condition each year, which can be “reliably diagnosed or excluded” using a CT scan, but “misdiagnosis affects one-third of patients”. A prevention of future deaths notice issued by Chris Morris, the area coroner for Greater Manchester South, written to Manchester University Foundation Trust, said: “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined or reviewed in person by a doctor." Read full story Source: The Telegraph, 21 October 2023
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News Article
Health Secretary backs Martha’s Rule giving right to second medical opinion
Patient Safety Learning posted a news article in News
The government has backed Martha’s rule, a campaign to give families and patients the right to a second assessment if they feel their concerns are not being taken seriously. Health secretary Steve Barclay said ministers are “committed” to implementing the rule, insisting the case for it is “compelling”. Martha Mills died after developing sepsis while under the care of King’s College Hospital NHS Foundation Trust in south London. Mr Barclay said the case set out by Ms Mills, was “compelling”. “For everyone that has heard it, it is an absolutely heartbreaking case,” he told the BBC. Mr Barclay said: “I’m determined that we ensure we learn the lessons from it and very keen to learn from best international practice.” Mr Barclay said there are “international lessons”, particularly from Ryan’s Rule in Australia, giving patients a direct line to a second opinion. “And I particularly want to give much more credence to the voice of patients,” Mr Barclay said. He added: “I think a key part of this measure is ensuring that patients feel heard and can get a second opinion.” Read full story Source: The Independent, 14 September 2023 -
News ArticleA private healthcare provider has been ordered to pay more than £1.5m – the largest fine issued for such a case – after pleading guilty in a criminal prosecution brought by the Care Quality Commission (CQC) over the death of a young woman at Cygnet Hospital Ealing in July 2019. It is the highest ever fine issued to a mental health service following a prosecution by the CQC. The firm pleaded guilty to one offence of failing to provide safe care and treatment, acknowledging failures to: provide a safe ward environment to reduce the risk of people being able to use a ligature; ensure staff observed people intermittently in line with the company procedures; and train staff to be able to resuscitate patients in an emergency. The offences related to the case of a young woman who was admitted to a ward in Cygnet Hospital Ealing in November 2018. In July 2019, she took her own life while on the ward. CQC said Cygnet Ealing had been aware the young woman tried to harm herself in an almost identical way four months earlier, but had failed to mitigate the known environmental risk she was exposed to. Read full story (paywalled) Source: HSJ, 21 September 2023
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News Article
Trans woman’s death ‘preventable with right support’, mother says
Patient Safety Learning posted a news article in News
The family of a young trans woman who is believed to have taken her own life have said she was “failed by those tasked with her care”, as the coroner investigating her death described services for transgender people as “underfunded and insufficiently resourced”. Alice Litman had been waiting to receive gender-affirming healthcare for more than three years when she died in Brighton at the age of 20 in May 2022. Ahead of an inquest which began in Hove on Monday, her mother, Dr Caroline Litman, described Alice’s death as “preventable with access to the right support”. Adjourning the inquest on Wednesday to give a narrative conclusion in two weeks’ time, the coroner Sarah Clarke told the court: “It seems to me that all of these services are underfunded and insufficiently resourced for the level of need that the society we live in now presents". Describing the trans healthcare system as “not fit for purpose”, Alice's family, who are being supported by the Good Law Project, added: “We are grateful that the coroner has agreed that the conditions of Alice’s death warrant a report to prevent future deaths.” Read full story Source: The Guardian, 20 September 2023 -
News Article
Patient's water drinking death was preventable
Patient Safety Learning posted a news article in News
The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found. The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death. An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water. It found several areas where a different course of action could have prevented his death. The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available. This move was described in the report as a "high-risk action". On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication. Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital. "We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed." Read full story Source: BBC News, 21 September 2023 -
Content ArticleThis is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
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Content ArticleThe 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 document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
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Content ArticleThe only masking that’s going on is that of the government’s continued failure to get to grips with the virus, writes George Monbiot in this Guardian opinion piece. For some people, going to hospital may now be more dangerous than staying at home untreated. Many clinically vulnerable people fear, sometimes with good reason, that a visit to hospital or the doctors’ surgery could be the end of them. Of course, there have always been dangers where sick people gather. But, until now, health services have sought to minimise them. Astonishingly, this is often no longer the case. Across the UK, over the past two years, the NHS has been standing down even the most basic precautions against Covid-19. For example, staff in many surgeries and hospitals are no longer required to wear face masks in most clinical settings. Reassuring posters have appeared even in cancer wards, where patients might be severely immunocompromised. A notice, photographed and posted on social media last week, tells people that while they are “no longer required to wear a mask in this area”, they should use hand sanitiser “to protect our vulnerable patients, visitors and our staff”. Sanitising is good practice. But Covid-19 is an airborne virus, which spreads further and faster by exhalation than by touch.
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News Article
Parents fear spread of ‘associate’ doctors at NHS will end in more tragedies
Patient Safety Learning posted a news article in News
A 30-year-old actress whose symptoms were dismissed as anxiety died of a blood clot. Emily Chesterton believed she had seen a GP, but had in fact been seen twice by a physician associate (PA), a newer type of medical role that involves significantly less training. Her parents, Brendan and Marion Chesterton, both 64 and retired teachers, said they have serious concerns about plans for thousands more PAs to be employed to combat staff shortages as part of the NHS Long Term Workforce Plan. Chesterton’s calf pain and shortness of breath should have suggested a pulmonary embolism and meant she was sent to A&E. A coroner concluded this would probably have saved her life. Instead she was told to take anxiety pills. She collapsed that evening. She was taken to hospital but her heart stopped and she could not be revived. Read full story (paywalled) Source: The Times, 10 July 2023 -
News ArticlePolice are investigating possible corporate manslaughter at the hospital where serial killer Lucy Letby worked. The former nurse, 33, was jailed in August for murdering seven babies and attempting to kill six others at the Countess of Chester Hospital. Cheshire Police said the latest investigation was in its early stages. Lawyers representing some of the victims' families said they were "reassured" steps were being taken to consider the actions of management. Organisations and companies can be found guilty of corporate manslaughter as a result of serious management failures resulting in a gross breach of a duty of care under The Corporate Manslaughter and Corporate Homicide Act 2007. Det Supt Simon Blackwell, of Cheshire Police, said the inquiry would focus on the indictment period of the charges for Letby from June 2015 to June 2016. He said the investigation would consider areas "including senior leadership and decision making to determine whether any criminality has taken place". "At this stage we are not investigating any individuals in relation to gross negligence manslaughter," he added. Read full story Source: BBC News, 4 October 2023
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Content Article
Tracking deaths, part 3: Patient Safety
Patient_Safety_Learning posted an article in Coroner reports
Patient harm due to unsafe care is the 14th leading cause of death and disability globally. In this paywalled blog, Dr Georgia Richards from the Preventable Deaths Tracker, looks at patient safety through the lens of avoidable deaths. -
Content Article
The truth for Gaia Young
Patient Safety Learning posted an article in Patient stories
Previously well, Gaia died aged 25 years of an unexplained brain condition hours after admission to University College Hospital London. Her death has been the subject of hospital investigations and an inquest. Over one year later her death remains unexplained. Why? This is her mother’s (Dorit) search for the truth: information is provided to stimulate medical crowd thinking – to ask the right questions and to get the right answers. Read the narrative of Gaia’s final illness in her mother’s story and in the memorandum from the link below. See also: Serious Incident Report: Unexpected deterioration of a young woman on the Acute Medical Unit: updated report (February 2022) -
Content ArticleThese videos posted by Melissa Sheldrick tell the story of her son Andrew, who died aged eight from a medication error. The investigation into Andrew's death found that he had been given baclofen by his pharmacy instead of the tryptophan he had been prescribed. When tested, the dose of baclofen in the bottle given to Andrew contained three times the lethal dose of baclofen for adults. PSMF Melissa's story. In this video, Andrew's mother Melissa talks about what happened to Andrew and how it led to her campaigning for mandatory reporting of medication errors by pharmacists across Canada, Australia and the US. Patients taking the lead: Collaborating for safer healthcare. This presentation was originally given at the World Health Organization's (WHO's) World Patient Safety Day conference on 12 September 2023 in Geneva, Switzerland. Melissa tells Andrew's story and talks about how she has raised awareness of gaps in accountability for pharmacies and pharmacists. She describes how she was invited to be part of a taskforce to improve safety in pharmacy by the pharmacy regulator in her home state of Ontario—this was the first time a member of the public had been included in such a taskforce.
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Content ArticleIf you are throwing up, having diarrhoea, drinking less water and/or have a fever, you can become dehydrated. Being dehydrated means your body doesn't have enough fluids. When you're dehydrated, some medications used to treat certain health problems may cause unwanted side effects, such as harm to your kidneys. It is important to have a plan to prevent these side effects in case you should become sick and dehydrated. The authors of this guidance learned about a person who died in hospital as a result of side effects of taking a particular medication while dehydrated. They were taking a diabetes medication called empagliflozin and kept taking the same dose after becoming sick. This medication is helpful for people with diabetes, but it can cause serious side effects if it's taken when the person is dehydrated. This guidance offers advice on how to reduce the risk of side effects from your medications when you are sick and dehydrated.
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Content ArticleHarold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his friend after his GP had discussed his case with doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following his arrival at 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non-survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease.
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News ArticleA coroner has warned that a private hospital is relying on NHS ambulances to transport patients despite “being fully aware” of the pressures on the ambulance service and resulting delays. The warning came at the end of an inquest into a patient who died after a 14-hour wait for an ambulance to transfer him from the private Spire hospital in Norwich to the NHS-run Norfolk and Norwich university hospital a few minutes’ drive away. The last two years have seen a succession of inquests relating to ambulance delays. But in the latest case Jacqueline Lake, senior coroner for Norfolk, expressed concerns over Spire hospital’s use of NHS ambulances when complications and emergencies mean its patients need NHS care. “Spire Norwich hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich university hospital,” Lake wrote in a prevention of future deaths (PFD) report. “Spire Norwich hospital continues to rely on EEAST [East of England Ambulance Service NHS Trust] to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.” Research suggests that nearly 600 patients were urgently transferred from private healthcare to NHS emergency care in the year to June 2021 across the UK – around one in a thousand private healthcare patients. But previous analysis by the Centre for Health and the Public Interest (CHPI) thinktank found that some private hospitals were transferring more than one in every 250 of their inpatients to NHS hospitals. ‘“Transferring unwell patients from a private hospital to an NHS hospital is a known patient safety risk which all patients treated in the private sector face – including the increased numbers of NHS patients who are now being treated in private hospitals because of government policy,” said David Rowland, director of the CHPI. “And despite numerous tragedies and despite the fact that politicians and regulators are fully aware of this risk, nothing has been done to address it.” Read full story Source: The Guardian, 23 September 2023
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Content ArticleOn 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function. Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours. The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b) Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus.
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Content ArticleThe latest data from the Office for National Statistics (ONS) provides the most comprehensive and up to date national profile of ethnic inequalities in mortality overall and from common physical conditions. It shows a complex picture of ethnic inequalities in mortality in England, with differences between people from ethnic minority and the White British groups, between different ethnic minority groups, and across different health conditions. This King's Fund blog looks at the complex interplay of factors drives ethnic differences in health.
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Content ArticlePatient harm due to unsafe healthcare is widespread, potentially devastating, and often preventable. Hoping to eliminate avoidable harms, the World Health Organization (WHO) published the Global Patient Safety Action Plan in July 2021. The UK's National Health Service relies on several measures, including ‘never events’, ‘serious incidents’, ‘patient safety events’ and coroners’ Prevention of Future Deaths reports (PFDs) to monitor healthcare quality and safety. This systematic narrative review of PubMed and medRxiv articles on 19 February 2023 aimed to explore the strengths and limitations of coroners’ PFDs and whether they could be a safety tool to help meet the WHO's Global Patient Safety Action Plan. The authors identified 17 studies that investigated a range of PFDs, including preventable deaths involving medicines and an assessment during the Covid-19 pandemic. The review found that PFDs offered important information that could support hospitals to improve patient safety and prevent deaths. However, inconsistent reporting, low response rates to PFDs, and difficulty in accessing, analysing and monitoring PFDs limited their use and adoption as a patient safety tool for hospitals. The authors concluded that to fulfil the potential of PFDs, a national system is required that develops guidelines, sanctions failed responses and embeds technology to encourage the prevention of future deaths.
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Content ArticleAs this year’s World Patient Safety Day celebrates the theme ‘Engaging patients for patient safety’, Dr Alan Fletcher, the National Medical Examiner for England and Wales, explains the connection between medical examiners and patient safety, and particularly the support they provide for bereaved people, whose insights and experiences can be crucial in supporting the NHS to learn and improve.
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Content ArticleThe Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
