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David Colin Strachan was aged 76 years when he died on 16 March 2022 at his home address in Uangollen, Denbighshire. At 23.20 hours on 15 March 2022, he experienced a sudden onset of chest pain, vomiting and became clammy with shortness of breath. A number of 999 calls were made to the Welsh Ambulance Service but it was not until 9.10am, some 9 hours and 52 hours from the initial call that an ambulance and paramedics arrived. An ECG by paramedics indicated that Mr Strachan had suffered an ST elevation myocardial infarction. He was conveyed directly to the North Wales Cardiac Centre at Ysbyty Gian Clwyd and following investigations he was transferred to the Coronary Care Unit. On arrival his breathing weakened and he died at 12.27pm on 16 March 2022 in hospital. The cause of death was recorded as: 1a. Acute myocardial infarction 1b. Coronary artery atheroma. Coroner's Matters of Concern: The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites. The matters of concern are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in border to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.

On the 9 October 2021 an investigation was carried out into the death of Ms Sandra Diane Finch, a 44 year old woman who had a history of Type 1 diabetes mellitus. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect.  The cause of death was: 1a) Ketoacidosis 1b) Uncontrolled Type 1 Diabetes Mellitus 1c) Insulin depravation. Sandra Diane Finch had recently had a dental procedure and was also recently prescribed antibiotics for an infection. It was accepted by clinicians that this can cause a Type 1 diabetic to need more insulin than they would normally need. On the 3 December 2021, Sandra's glucose levels started to rise. On the 4 December 2021, Sandra called the West Midlands Ambulance Service and told them she was feeling more sleepy, her glucose was high and she had been vomiting. The categorisation of this call was category 3. This meant she was a medical emergency and required an ambulance. However, before an ambulance could be dispatched a clinical review was required by the CV team. The team was under staffed and had no time limit attached for an assessment. As such, an attempt for an assessment did not take place until 10 hours later. At 12:47 on the 5 December 2023 the decision was made by the team to categorise the ambulance request as a category 2 and dispatch an ambulance. This arrived at Sandra Diane Finches address at 13:08 and she was found to have passed away as a result of ketoacidosis. The view of clinicians was that had the ambulance been despatched within the accepted time limit for a category 3 ambulance, Sandra Diane Finch would not have died when she did. Matters of concern That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays.

Missed checks, disrupted care and health inequalities have been revealed in a new report from Diabetes UK looking at the state of diabetes care in England. The report reveals that less than half (47%) of people living with diabetes in England received all eight of their required checks in 2021-22, meaning 1.9 million people did not receive the care they need.  It is calling for urgent action to address the routine diabetes care backlog and prevent avoidable deaths of people living with diabetes.  The report sets out a series of recommendations for how this care crisis can be tackled. It is calling for: A focus on diabetes in the government’s Major Conditions Strategy, including plans to tackle the backlog in diabetes care, reduce health inequalities and provide more support to help people lower their risk of developing type 2 diabetes A fresh commitment from the government to implement its stalled obesity strategy in full and without further delay, including restrictions on junk food marketing Commitments in the plans of every Integrated Care Board in England to address the backlog in care, inequalities in access to care and to put type 2 diabetes prevention at the heart of their strategies.

Last November’s HSJ Patient Safety Virtual Congress focused on the COVID-19 virtual ward model, which enables the early identification and timely management of deteriorating patients in the community - a critical step in reducing avoidable deaths from all conditions. If you missed the vital discussion, you can check it out below.

In April 2009 a ‘considerative checklist’ was developed to ensure that all important aspects of care on a team's routine and post-take general internal medicine ward rounds had been addressed and in order to answer the question: How long should a ward round take, when conducted to high standards of quality and safety at the point of care? The checklist has been used on 120 ward rounds: 90 routine ward rounds and 30 post-take ward rounds. Overall, the average time per patient was 12 minutes (10 minutes on routine rounds and 14 minutes on post-take rounds). The considerative checklist has encouraged and enabled documented evidence of high quality and safe medical care, and anecdotally improved team working, communication with patients, and team and patient satisfaction.

Good foot health and care play an important role in improving overall health and wellbeing of the general population. However, the observations of nurses and podiatrists suggest that people experiencing homelessness, particularly rough sleepers, experience worse foot health than the wider population.  This guidance, from the Queens Nursing Institute, was developed in partnership with podiatrists with experience of working with people who are homeless, and is intended as a resource for community nurses and allied health professionals. It can be used as a reference by others with an interest in the health of people who are homeless, such as hostel staff, day-centre staff and support workers. 

Early warning scores are widely used prediction models that are often mandated in daily clinical practice to identify early clinical deterioration in hospital patients. In this paper published in the BMJ, Gerry et al. carried out a systematic review and critical appraisal of early warning scores for adult hospital patients. The results found that many early warning scores in clinical use had methodological weaknesses.The study's authors concluded that the early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care.  “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.”

Our experience of attending the Patient Safety Learning Annual Conference and entering our patient safety initiative into the awards. We have a new app within Homerton which is featured on the hub. The Homerton University Hospital (HUH) Action Card App is an initiative that aims to bridge the gap between information/processes with clinical members of staff without the need to log into a computer, access the intranet, and finding the long black and white document which is never ending. The Action Card App has easy to read, 1-page coloured documents relating to local and national/local incident trends and Never Events. We entered the Patient Safety Learning Awards on the back of seeing the hub and finding content on there that was incredibly useful on a day to day basis. We genuinely weren't expecting to hear anything back from the Patient Safety Learning team as we are a small trust that not a lot of people know about, and we thought the standard of patient safety initiatives would be high, with many trusts miles ahead of us. I have to say, the team at Patient Safety Learning were nothing but lovely, from the moment the conversation started about the prospect of entering the awards. They all took the time for correspondence and they treated you as a person, as oppose to an entry. When we got the information that we had won the overall prize, we were gobsmacked and elated. The app team were overjoyed with the sense that our hard work had paid off and someone had taken the time to appreciate the work we have been doing at Homerton. We were asked to prepare a presentation prior to the awards, which showcased our work and to share with the attendees of the conference. The day arrived, with so much great work, inspiring talks and a general atmosphere of wanting to do more to keep our patients safe. I would like to thank everyone who heard our presentation (some may say performance) and thank everyone in the Patient Safety Learning team for their help with this process.

Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? My much loved daughter-in-law, Mariana Pinto, died on 16 October 2016. She was 32. Her tragic and unexpected death raised many questions for us about standard practice by psychiatric services and about patient safety. The evening before she died, Mariana was taken by ambulance to her local A&E department, escorted by four police officers, and handcuffed for her own safety. She was psychotic – delusional, paranoid, violent and very distressed. She had attacked her husband (my son) who had visible bite marks, scratches and bruises. It was a first episode and totally out of character. She had not eaten or slept for several days. In A&E she was brought food and drink but spat it out, believing it to be poisoned. She kept trying to escape from the cubicle. The police stayed, stating that she was extremely vulnerable. Eventually she agreed to take a sedative – but not before she had held it under her tongue for some time, and only after we, her family, were able to persuade her that she should take it. Once she was finally sedated, she was given various tests to rule out any physical cause, and a mental health act assessment. This was done with her and her husband together. There was no attempt to see him separately. She was deemed competent to make decisions about her care, and as she wanted to go home, was discharged, with a referral to the local Crisis Team, who we were told would receive the referral at 8 am the following morning and would arrange to visit. The psychiatric team operate within A&E but for a separate mental health trust. This same trust runs the Crisis Team. It is deemed outstanding by the Care Quality Commission (CQC). The following morning, there was no contact from the Crisis Team. My son rang them at midday to ask when they would visit. They said normally between 5 and 7 pm on Sundays and to ring back if he needed to. He rang back at 3.30 pm stating that she had deteriorated rapidly and asking for the visit to be brought forward. He was told that it could not be. At 4.00 pm Mari ran out of the open door to the roof terrace and jumped off it. She did not survive her injuries. The Coroner gave a narrative verdict, making it clear that Mariana did not know what she was doing, though her actions were deliberate. She also gave a Prevention of Future Deaths Report. Whilst the trust is obliged to reply, there is no statutory obligation to demonstrate that the actions they have promised have actually been taken. There was no attempt at any risk assessment. There was no attempt to check that my son could speak freely (he could not – it was a studio apartment). There was no attempt to call the emergency services on his behalf, and no attempt to check he had been able to do so. None of this is regarded as negligent or especially problematic. Since her death the Crisis Team do visit on Sunday mornings. We also found out that the number we were given to call was for service users already allocated a key worker, rather than a more general number – but as my son spoke to senior staff on each call, this should not have made a difference. After her death we raised the following questions: Surely given the bite marks and bruising, her husband should have been allowed to give his information to the psychiatric team separately? No, it turns out that while this would have been good practice, it was not negligent. Surely, given that her family knew and loved her, we should have been asked post sedation if she seemed like herself (she did not). No, it turns out that this is not seen as necessary. It’s not even regarded as good practice. Surely, given that she was paranoid and had told the police that she did not trust her husband, her husband should have been given private space to discuss the discharge and rehearse what to do if things went wrong once the sedative wore off? And surely we should have been told that the Crisis Team is not instead of calling 999 in an emergency. And efforts made to help us to decide if the situation was an emergency. No, it turns out that while this would have been good practice, it was not negligent. The mental health trust has now introduced a written discharge template for care and contingency planning. We have been told that the circumstances of Mariana’s death were unusual and could not have been foretold. That may be. But there are still lessons to be learnt. To improve patient safety in mental health crisis and to learn from deaths, we need to change standard practice. It should become standard to: See family and friends separately if someone is paranoid, to understand the family’s concerns, learn more about the patient and work together to consider how best the patient can be kept safe and helped. Provide written care and contingency plans to patients and their family Use one number for a Crisis Team helpline, with clear policies to offer help and support to service users and to their carers, and proper protocols in place to assess risk and intervene if someone is at immediate risk of harm. Make it very clear to patients that a referral to a Crisis Team is not a substitute for calling 999 in an emergency (where there is an immediate risk of harm to the patient or others) and to distinguish between a crisis and an emergency. Other professionals have a role in this too: On discharge, the A&E staff (who were very kind and very concerned) could invite the family to come back if the situation deteriorates, making it clear that it was an emergency, was a legitimate use of 999 and of A&E, and that the Crisis Teams are not for emergencies. The police could do the same, if they are trusted by the family (in many cases they are not).

Following the inquest into the death of former patient Amy Allan and the subsequent Preventing Future Deaths report given to Great Ormond Street Hospital for Children, Chief Executive Matthew Shaw would like to outline how the hospital is learning from this and what action has been taken to address the concerns that have been raised. Following a review of the events that led up to Amy’s death Great Ormond Street Hospital have already made changes to practice: They have improved the way clinical information is shared between different specialist teams, to make sure staff have as comprehensive a picture as possible when making complex decisions about a patient’s treatment. They now use a single log-in electronic patient record system which means staff can quickly access clinical information about a patient and have the right information at the right time, rather than routinely having to use multiple systems. They have improved consultant availability. This means there is more consultant time for each patient being looked after in our paediatric intensive care unit. They have introduced a new process to make sure the care of patients, like Amy, who have both complex spinal and heart conditions is routinely considered by the hospital’s specialist joint cardiology committee.