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Showing results for tags 'Coroner reports'.
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Content ArticleIn her report, the coroner highlights two matters of concern in this case: Initial delay in seeing a doctor Mr Collinson was not seen by a Doctor until eight hours after he arrived at hospital. The reason given for this was that the department was highly pressured on this date, and although a junior doctor had assigned the case to them by "clicking", that doctor had not in fact been able to see Mr Collinson. He did not "unclick" the patient and therefore other doctors who may have had capacity were not aware that Mr Collinson had not been seen. The coroner expressed concerns that
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Content ArticleMrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered. Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to re
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News Article
Inquest hears evidence of mistakes in Nightingale patients’ care
Patient Safety Learning posted a news article in News
An inquest into the death of a London bus driver at London’s Nightingale Hospital during the first wave of coronavirus has heard evidence about equipment mistakes which may have harmed patients. Kishorkumar Patel, aged 58, was one of the first patients to be admitted to the field hospital at London’s Excel Conference Centre in April last year. An inquest at East London Coroner’s Court was told doctors and nurses were forced to work “leanly” because of limited staff and ventilators to help patients breathe. Mr Patel is one of 10 patients who had the wrong filter used on the venti -
News Article
Concern raised over death of five patients seen remotely by GPs
Patient Safety Learning posted a news article in News
Patients being assessed remotely in general practice, rather than face-to-face, has been raised as a risk in reports on five deaths by a single coroner since the pandemic hit. Senior coroner for Greater Manchester Alison Mutch has written five prevention of future deaths reports highlighting concerns that doctors were missing details in telephone appointments which may have been spotted, had the patient been seen in person. The reports cover a variety of conditions, including covid, a broken femur, and anxiety and depression. In March 2020, NHS England guidance instructed GPs to adop -
Content Article
Prevention of Future Deaths report – Ann Geraghty
Patient Safety Learning posted an article in Coroner reports
While under continual cardiac monitoring from the 6– 8 March 2021, Ann Geraghty experienced two periods of ventricular standstill which were recorded but missed. Had these been detected she would have been admitted into a Critical Care Unit, though the Coroner noted that her subsequent cardiac arrest could not have been prevented. The Coroner raises concerns that: The Philips central monitoring station used by the hospital detected the two periods of ventricular standstill but its alarm notification self-terminated when the heart rhythm had corrected. Following the Trust’s i -
News ArticleShortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer has revealed, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision. The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”. Coroners issu
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Content ArticleIn 2020, 4,561 deaths related to drug poisoning were registered in England and Wales (equivalent to a rate of 79.5 deaths per million people); this is 3.8% higher than the number of deaths registered in 2019 (4,393 deaths; 76.7 deaths per million). A worrying statistic, which the Transform Drugs Policy Foundation describes as #50YearsOfFailure: "For over 50 years, the war on drugs has caused injustice, suffering and tragedy to communities across the world. It's time to bring it to an end." In summary there were a record 2996 drug-related deaths in 2020: opioid deaths up
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Content ArticleIn the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that
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News Article
Deaths of people with learning disabilities deserve proper scrutiny
Patient Safety Learning posted a news article in News
The critical finding at the inquest into Laura Booth’s death raises alarming concerns about the failing system of investigation into the deaths of people with learning disabilities. Initially, Laura’s death was said to be expected and was attributed to natural causes on the basis of a death certificate signed by a hospital doctor. Without the determination of Laura’s family and the intervention of the media, this inquest would never have happened, and the truth about her death from malnutrition and neglect would not have been uncovered. The concerns about how many other avoidable de -
Content ArticleThe author of both reports, Margaret Jones HM Assistant Coroner, notes the matters of concern are as follows: The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector. Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change. The Hospital Trust did not fully evaluate the size 14F
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Content Article
Prevention of Future Deaths Report – Gary Day
PatientSafetyLearning Team posted an article in Coroner reports
Evidence showed that: 1. Mr Day was not informed that there was any risk of death from the surgery he elected to have, even though there is a risk of air embolus, and therefore death, from this procedure. The Consent Form he signed did not make any reference to a risk of death. 2. There was no check carried out for air embolus after the operation. 3. There was confusion between medical staff as to whether or not Mr Day was to be kept in for an over-night stay in hospital. As it turned out, he was not advised to stay in hospital over-night. 3 Mr Day was allowed to leave 3 ho -
News Article
Inquest finds neglect contributed to woman’s hospital death
Patient Safety Learning posted a news article in News
The death of a young disabled woman following a routine eye operation was partly caused by malnutrition as a result of neglect, a coroner has ruled. Laura Booth, 21, was admitted to the Royal Hallamshire hospital in Sheffield in September 2016 for a routine eye operation. She died the next month, on 19 October. Booth had a number of learning difficulties and life-limiting complications, having been diagnosed with partial trisomy 13, a rare genetic disorder, shortly after she was born. Her mother, Patricia Booth, told the inquest that her daughter stopped eating shortly after she -
News Article
'Anger' over report into neglect death care home
Patient Safety Learning posted a news article in News
The mother of a man who died after suffering neglect said she felt "extreme distress and anger" at a critical new report into his care home. James Delaney, 37, died while he was a resident at Sapphire House in Bradwell, Norfolk, in July 2018. After an inadequate rating by the Care Quality Commission (CQC), Mr Delaney's mother said she felt lessons had not been learned from her son's death. A spokeswoman for operator Crystal Care said it had "addressed all concerns". Mr Delaney, who died of a diabetes-related illness, was required to take insulin twice a day, but, despite staff n -
Content ArticleThe Coroner notes that, although he was assessed at home by the midwifery team at aged 5 days, no basic observation assessments were taken, such as temperature, heart rate and respiration rate, from the deceased or his mother to confirm their wellbeing. There is no national guidance for such checks, however, University Hospital Dorset NHS Foundation Trust (UHD) have since changed their local policies to embed better safety nets. The local policy now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken. The Coroner also
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Content Article
Prevention of Future Deaths report – Jamie Poole
Patient Safety Learning posted an article in Coroner reports
Coroner, Emma Serrano, concluded in the coroner's report that transplant patients are put on strong immunosuppressive medication to prevent rejection of the transplanted organ. The medication, tacrolimus in Jamie Lee Pools case, has a common known side effect of reducing magnesium levels within the body. This can be life threatening. Despite this, it is not standard practice to regularly test transplant patients magnesium levels. Whilst the Trust providing care for Jamie Lee Poole, has now remedied this, and routinely test posttransplant patients’ for magnesium levels, this is not the cas -
News ArticleA world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was
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News ArticleAs she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff. Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government. The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in
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Community PostHi All, I was looking through a recent coroners case ( https://www.judiciary.uk/wp-content/uploads/2020/01/Julie-Taylor-2019-0454.pdf ) Where a learning disability patient deteriorated while in an acute care setting. One of the recommendations was that the Trust should have used a 'reasonable adjustment care plan'. I haven't heard or seen one of these before. So I had a quick look on the internet and found this. http://www.bristol.ac.uk/sps/media/cipold_presentations/workshop3presentation1-linda-swann.pdf Does anyone else use a care plan that they wouldn't mind shar
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Content ArticleThe aim of this study from Leary et al. was to examine the feasibility of extracting data from these reports and to evaluate if learning was possible from any common themes. In total 710 reports were examined, with 3469 concerns being raised. Thirty-six reports expressed concern about having to issue repeat PFDs to the same organisation for the same or similar concerns. Thematic analysis reliability was high (κ 0.89 unweighted) with five emerging primary themes: deficit in skill or knowledge, missed, delayed or uncoordinated care, communication and cultural issues, systems issues and lack
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News Article
Coroner orders closer working between five trusts after prisoner’s death
Patient Safety Learning posted a news article in News
Five NHS trusts in the South West have been ordered to make immediate improvements after the death of a 20-year-old prisoner who needed healthcare. Lewis Francis was arrested in Wells, Somerset, in 2017 after stabbing his mother while “acutely psychotic” and taken into custody. Although his condition mandated a transfer to a medium secure mental health hospital, there was “no mechanism” in place to move Mr Francis and he was taken to prison, where he died by suicide two days later, according to a coroner. Contributory factors to his death included “insufficient collaboration, communi -
Content ArticleI believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
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Content ArticleWhat are PFD reports? There is a statutory duty for coroners to issue a PFD report to any person or organisation where, in the coroner’s opinion, action should be taken to prevent future deaths. These reports are made publicly available on the Coroners Tribunals and Judiciary website with the organisations involved having a duty to respond within 56 days. When serious incidents occur in healthcare that result in the death of a patient, PFD reports play a key role in identifying what went wrong and the actions needed to prevent this reoccurring. These crucial insights may often be appl
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News ArticleA 40-year-old mother of four took her own life at an NHSmental health unit after multiple opportunities were missed to keep her safe, an inquest has found, prompting her family to call for a public inquiry. Azra Parveen Hussain was allegedly the seventh in-patient in seven years to die by the same means while in the care of Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHT). Despite this, an inquest at Birmingham and Solihull Coroner’s Court last week heard that the Trust had not installed door pressure sensor alarms, which could have potentially alerted staff to the
