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Found 84 results
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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.
  8. 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
  9. 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
  10. 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
  11. 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
  12. News Article
    Patients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prev
  13. News Article
    Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not
  14. Content Article
    The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem. A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where
  15. Content Article
    What are PFD reports? Coroners have a duty to decide how somebody came by their death and also, where appropriate, to report about that death with a view to preventing future deaths.[1] [2] These reports follow a set template format and are issued by the Coroner to any person or organisation where, in their opinion, action should be taken to prevent future deaths. These reports are made publicly available online and the persons/organisations involved having a duty to respond within 56 days. PFD reports relating to deaths in health and social care settings can help to identity what wen
  16. News Article
    The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people ex
  17. Content Article
    Coroner's Matters of Concern The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. Although I unde
  18. News Article
    A man who died from a mixed medication overdose might still be alive if the help his partner was "begging" for had been provided, a coroner said. Mental health patient Benjamin Stroud, 42, had been under the care of Essex Partnership University NHS Trust (EPUT) in the weeks before his death in March. Essex coroner Michelle Brown said in a post-inquest report that, despite "escalating psychosis", his care co-ordinator did not flag the case. Following an overdose of medication in February, his partner, a nurse, called for psychiatric intervention and despite "begging" for help, Mr
  19. Content Article
    Mr Stroud had been admitted from A&E under section 2 of the Mental Health Act between the 16 and 24 January 2021, to the Lindon Centre. He was then released under the ambit of The Gables and had been seen by a psychiatrist whilst under section 2. This appeared from the evidence to be the only time he was seen by such a person. On the 22 February 2021, he took an overdose of insulin; however, as his partner is a nurse, he didn’t attend hospital as she knew what to do. A PSIIR report and action plan was completed. Mr Stroud’s partner gave evidence, and it was clear from her account that
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