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Found 97 results
  1. Content Article
    Coroner's Matters of Concerns: Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). There needs to be better education both to doctors and to patients in risk groups to prevent future death. In relation to Pathology: The current
  2. News Article
    A coroner has written to the health secretary warning a lack of guidance around a bacteria that could contaminate new hospitals' water supply may lead to future deaths. It follows inquests into the deaths of Anne Martinez, 65, and Karen Starling, 54, who died a year after undergoing double lung transplants at the Royal Papworth Hospital in Cambridge in 2019. Both were exposed to Mycobacterium abscessus, likely to have come from the site's water supply. The coroner said there was evidence the risks of similar contamination was "especially acute for new hospitals". In a pre
  3. Content Article
    Coroner's concerns 1 It is recognised that M. abscessus poses a risk of death to those who are immunosuppressed. That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients. To date, 34 patients at Royal Papworth have contracted M. abscessus from the hospital’s water. Cases continue to be reported, albeit at a declining rate. 2 There is an incomplete understanding of how M. abscessus may enter and/or colonise a hospital water system. 3 Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by
  4. News Article
    More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issu
  5. News Article
    A key national policy change recommended by the inquest which led to the East Kent maternity inquiry will not be implemented until next February – more than three years after it was called for by a coroner. The recommendation – that obstetric locum doctors be required to demonstrate more experience before working – was made in a prevention of future deaths report following the inquest into the death of seven-day-old Harry Richford at East Kent Hospitals University Foundation Trust. The remaining 18 recommendations from the PFD report were requiring specific actions by the trust, rath
  6. Content Article
    Coroner's concerns and recommendations Concern 1 X was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital. This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. X gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trust
  7. Content Article
    Coroner's concerns Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care. The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation. The primary responsibility fell upon the famil
  8. News Article
    A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in
  9. Content Article
    Coroner's concerns Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of obser
  10. News Article
    A private hospital has been rated ‘inadequate’ by a health watchdog following an inspection prompted by a young patient’s preventable death. Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May. The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020. Mr Caseby had been detained under the Mental Health Act but m
  11. Content Article
    Coroner's concerns Whilst at King’s College Hospital, Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries. The bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to the coroner very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of child
  12. News Article
    A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead t
  13. Content Article
    Coroner's concerns The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be a
  14. Content Article
    Coroner's concerns Without changes in the NHS Pathway the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: at the time of the conclusion of the inquest, there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five at the time of the conclusion of the inquest, the question regarding green vomit, asked in respect to children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was
  15. Content Article
    Matters of Concerns: Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information. Whilst since this event there have been steps to provide training of staff at 111 and Out of Hours services and NHS Digital have reworked the pathways to deal with multiplicity of symptoms there are still concerns re what further steps may be taken regrading cases invo
  16. News Article
    Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to
  17. Content Article
    Matter of concerns: Inadequate training of doctors and other medical professionals re the risk of sepsis following Early Medical Terminations. Evidence from a wide range of clinicians who had cared for Sarah in March and April 2020 echoed each other. The clinician evidence revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following Early Medical Termination. The hospital trust accepted that at the time of Sarah’s death, there was confirmat
  18. Content Article
    Coroner's concerns There were excessive delays in handing over patients at hospital. The West Midlands Ambulance Service Serious Incident report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands.
  19. Content Article
    The recent Patient Safety Learning report, 'Mind the implementation gap: The persistence of avoidable harm in the NHS', highlights some important challenges and barriers to patient safety improvement, not only for the NHS in the UK but globally for health systems across the world. In many countries, including my country, Ethiopia, various investments have been made to improve the safety of healthcare delivery. We have been setting national minimum requirements/standards for health facilities, ethics and competence review systems for health professionals, but we have never had the confiden
  20. Content Article
    The Matters of Concern are as follows: For the Priory Hospital: 1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. There are serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost. 2. Record Keeping quality: The
  21. News Article
    "I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes. Eight weeks later, Brooke took her own life. The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to he
  22. Content Article
    Brooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to
  23. News Article
    A 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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