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Showing results for tags 'Coroner reports'.
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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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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 -
Content Article
Prevention of Future Deaths report – Brian Button
Patient Safety Learning posted an article in Coroner reports
Prevention of Future Deaths report – Brian Button Response from the Royal Sussex County Hospital -
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
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Content Article
Prevention of Future Deaths report – Averil Hart
Patient Safety Learning posted an article in Coroner reports
The following concerns are highlighted in the report: Inadequate training of doctors and other medical professionals re eating disorders. Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk anorexia nervosa patients by primary or secondary care providers. Lack of robust and reliable data regarding the prevalence of eating disorders. The impact of the COVID 19 pandemic. -
News Article
Hospitals failing to heed warnings over patient deaths, reveals new study
Patient Safety Learning posted a news article in News
Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to -
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 calls for new guidance on umbilical venous catheters after baby’s death
Patient Safety Learning posted a news article in News
A newborn baby died after doctors caring for him failed to realise that the umbilical venous catheter (UVC) through which he was being fed and medicated was wrongly positioned, a coroner has found. Anna Crawford, assistant coroner for Surrey, called for guidelines from the National Institute for Health and Care Excellence (NICE) on the use of the catheters after hearing that none currently exist. Yo Li was born extremely prematurely at St Peter’s Hospital in Chertsey on 11 January 2019 and transferred to the neonatal intensive care unit, where he was put on mechanical ventilation. A -
News Article
Staff 'missed opportunities' to save patient
Patient Safety Learning posted a news article in News
Staff at a mental health unit missed "multiple opportunities" to realise a woman had become unwell before she died, a coroner has said. Sian Hewitt, 25, died at Milton Keynes Hospital last year after collapsing at the nearby Campbell Centre. Coroner Tom Osborne said there was "a failure to start effective CPR". A spokesman for the centre said changes have been made to how care is delivered. Ms Hewitt, who had Asperger's syndrome and bipolar disorder, was admitted to the inpatient unit on 13 March 2019. She died less than a month later on 6 April 2019 at Milton Keynes Hospit -
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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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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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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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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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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 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 ArticleInquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertai
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