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News Article
Questions after three disabled children at same care home die
Patient Safety Learning posted a news article in News
Three disabled children died in similar circumstances at the UK's largest brain rehabilitation centre for children despite warnings about care failings, The Independent can reveal. Five-year-old Connor Wellsted died in 2017 at The Children's Trust’s (TCT) Tadworth unit in Surrey, having suffocated when a cot bumper became lodged under his chin. Six years later, in 2023, Raihana Oluwadamilola Awolaja, 12, died after her breathing tube became blocked, and Mia Gauci-Lamport, 16, died after she was found unresponsive in her bed. Inquests into all three deaths uncovered a litany of failings and identified common problems in the children's care at the home where multiple senior directors earn six-figure salaries. Now, police have launched a fresh investigation into Connor’s death. Coroners who investigated their deaths criticised staff for failing to adequately monitor the children – all of whom had complex disabilities and needed one-to-one care – and for not sharing the full circumstances of how they died with authorities. The families of the children, who were all under the care of their local council, are demanding that the government and the regulator, the Care Quality Commission (CQC), take action. Speaking to The Independent, Connor’s father, Chris Wellsted, said: “How many more children are going to die because of their incompetence? CQC failed, NHS England failed. The government failed. Every organisation that should have been investigating the children's trust. It’s a disgrace.” Read full story Source: The Independent, 10 June 2025- Posted
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Hospital 'deeply sorry' after 12-year-old's death
Patient Safety Learning posted a news article in News
A hospital boss has apologised "unreservedly" after the death of a 12-year-old girl which led a coroner to raise concerns about the "discrimination of disabled children". Rose Harfleet died at Royal Surrey County Hospital, in Guildford, on 30 January 2024, having attended its emergency department the day before with abdominal pain and vomiting. Assistant coroner for Surrey, Karen Henderson, said in a recent report that there was a failure of the medical and nursing staff to appreciate Rose was clinically deteriorating. The coroner said Rose, who from birth was diagnosed with mosaic trisomy 17 with global developmental delay, was "wholly reliant on her mother to advocate on her behalf". But she said at the hospital no history was taken from Rose's mother and that the severity of her signs and symptoms were underestimated. She said poor clinical decisions contributed to Rose's death. "This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children," she added. Read full story Source: BBC News, 4 June 2025- Posted
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A coroner has warned of a "culture of cover-up" at a care home where neglect contributed to the death of a disabled 12-year-old girl. Raihana Awolaja, who required 24-hour one-to-one care, died of cardiac arrest in 2023 after her breathing tube became clogged while she was left alone at Tadworth Court in Surrey, a residential care facility operated by The Children’s Trust. Now a senior coroner looking into her death, Professor Fiona Wilcox, has written to the Trust's chief executive, warning there could be further deaths at the home if improvements aren't made. Prof Wilcox raised several serious concerns about the home, including that severely disabled children may not be receiving the level of care needed to keep them safe and more staff training was required. She also warned there "may be culture of cover up at Tadworth Children’s Trust". She added: "They carried out a flawed investigation after this incident, pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning and thus risking lessons that should be learned are lost that could prevent future deaths." Read full story Source: ITV News, 21 May 2025- Posted
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‘No staffing growth’ policy implicated in patient’s death
Patient Safety Learning posted a news article in News
Repeated refusals by NHS England to fund extra staff was a key factor in a patient’s death, a coroner has said. The coroner warned that year-long delays to follow-up appointments at the Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust were a factor in the death of Peter Anzani, a spinal injury patient who died from a blood clot in November last year. NHS England turned down two requests to fund extra staff at the trust due to national policy and “a funding shortage”, a recent prevention of future deaths report has said. That’s despite RJAH struggling with patient demand and staffing shortages, leading to longer waits for reviews and treatments, according to the report. Adam Hodson, the coroner for Birmingham and Solihull, said in the report sent to NHSE and the hospital: “It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or reviews, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment.” He added: “It is concerning to hear that the trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming).” Read full story (paywalled) Source: HSJ, 22 May 2025- Posted
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At 10.45am on 23 November 2024, Peter Anzani sadly died from a pulmonary embolism in Birmingham Heartlands Hospital. He had been admitted to hospital the day before and was receiving treatment for a community acquired pneumonia when he suddenly and unexpectedly collapsed due to a pulmonary embolism. Peter had previously suffered a number of falls at home in August and September 2021 and was subsequently diagnosed with suffering a spontaneous infection of the cervical vertebral canal which caused a complete spinal cord injury and left him tetraplegic. This made him more vulnerable to chest infections and pulmonary embolisms which he experienced in the years that followed. There is no evidence of any human intervention that rendered his death unnatural. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Pulmonary Embolism 1b 1c 1d II Pneumonia Spinal cord injury resulting in Tetraplegia Matters of concern To The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust I considered evidence from a [REDACTED] who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by theTrust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms…” It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. To NHS England / Department of Health and Social Care I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (“The Trust”) have been experiencing difficulties with patient waiting lists – due to both an increase in the quantity of patients being treated and staffing shortages – which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a “no growth policy”. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming). It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or reviews, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment. In light of HM Government’s decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance.- Posted
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Senior doctor accused of failures in case that gave rise to Martha’s rule
Patient Safety Learning posted a news article in News
A senior doctor has been accused of wrongly failing to escalate the care of a 13-year-old girl whose death led to the adoption of Martha’s rule, which gives the right to a second medical opinion in hospitals. At a disciplinary tribunal in Manchester, Prof Richard Thompson was also said to have provided a colleague with “false and misleading information” about the condition of Martha Mills. Martha died on 31 August 2021 at King’s College hospital (KCH) in south London after contracting sepsis. In 2022, a coroner ruled that she would most likely have survived if doctors had identified the warning signs of her rapidly deteriorating condition and transferred her to intensive care earlier, which her parents had asked doctors to do. Thompson, a specialist in paediatric liver disease, and the on-duty consultant – although he was on call at home – on 29 August 2021, is accused by the General Medical Council (GMC) of misconduct that impairs his fitness to practise. Opening the GMC’s case at the Medical Practitioners Tribunal Service on Monday, Christopher Rose said, based on a review of the case by Dr Stephen Playfor, a medical examiner at Manchester Royal Infirmary, Thompson: Should have taken more “aggressive intervention” between noon and 1pm on 29 August, including referring Martha to the paediatric intensive care unit (PICU). Should have gone into the hospital from about 5pm to carry out an in-person assessment of a rash Martha had developed. Gave “false, outdated and misleading information” in a phone call at approximately 9.40pm to Dr Akash Deep in the PICU team. Read full story Source: The Guardian, 19 May 2025- Posted
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Earlier C-section could have saved baby
Patient Safety Learning posted a news article in News
A baby who died three days after birth would have survived if her mother had been offered a caesarean section, a coroner has said. Emmy Russo was delivered at Princess Alexandra Hospital in Harlow but died on 12 January 2024. Mother Bryony Russo told an inquest at Essex Coroner's Court that her requests for a C-section were "laughed off" during the hours she was there in labour. Assistant coroner for Essex, Thea Wilson, said there were five missed opportunities to offer Ms Russo a C-section, and that Emmy's chances would have been different had she been born an hour earlier. "She would have been born in a better condition and on the balance of probabilities she would have survived," she said. "There was a failure to respond adequately to the request for a C-section" Independent expert obstetrician Teresa Kelly had told the coroner there was enough evidence "this baby wasn't coping with labour" and staff should have acted sooner. Giving evidence, midwife Megan Fletcher defended her decision not to escalate concerns to a more senior doctor, saying she was trying to avoid any further "invasive procedures". Read full story Source: BBC News, 7 May 2025- Posted
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Hospital criticised for ‘poor’ and ‘defensive’ investigations
Patient Safety Learning posted a news article in News
A hospital trust has been criticised for its “poor” and “defensive” investigations into three deaths, which a coroner has linked to care by a single surgeon. Heidi Connor, senior coroner for Berkshire, investigated three deaths that occurred within three months at Royal Berkshire Foundation Trust. Each death followed surgery by consultant colorectal surgeon Daniel McGrath, whose “management” of each case was criticised by experts cited by the coroner. The coroner’s prevention of future deaths report about the death of Lorraine Parker, who died most recently of the three on 30 March 2024, was published last week and examined the trust’s death investigations processes across each of the three cases. Ms Connor found the trust’s structured judgement reviews - which investigate care failings following a patient death - to be “at best, poor” and “at worst, defensive”, and warned the trust that its overall death investigation process “is not working well”. In addition, the coroner questioned “whether the trust has done enough to deal with the concerns about this particular surgeon” following the three deaths. There is no note of a restriction on Mr McGrath’s practice according to the General Medical Council register. However, Royal Berkshire told HSJ it has “worked closely with the coroner and the GMC” on measures to oversee his work. He has also been removed from surgical duties. Looking at how the trust handled investigations into the three deaths, the coroner’s report noted the trust did not carry out a “detailed [Patient Safety Incident Response Framework] report”, which supports responses to patient safety incidents, into any of the deaths. Read full story (paywalled) Source: HSJ, 1 May 2025- Posted
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Lorraine Parker’s death was the third within three months at Royal Berkshire Foundation Trust following surgery by the same consultant colorectal surgeon. With the permission of both families, the coroner referred to two previous inquests – Mr MR (date of death 4 March 2024), and Mr ME (date of death 28 December 2023) – to focus on the trust’s death investigation processes, and how efficient they have been in terms of picking up issues following each of these deaths. The coroner instructed independent colorectal surgery experts to comment on the management, using two different experts for the three cases. The coroner made the following findings: In the case of Mr ME, a significant surgical error was made when a healthy part of the bowel was removed instead of the area with the cancer, resulting in a much more extensive operation and Mr ME dying around 5 weeks later. This was discussed in a morbidity and mortality meeting, which ends with the simple phrase “await coroner’s report”. A structured judgment review was carried out by a consultant colorectal colleague on 4 May 2024, over four months after the death. According to this review, all of the care given to Mr ME was either “good” or “excellent”. A further structured judgement review took place. It would appear that none of the colorectal surgeons was willing to carry this out, resulting in the need for a gastroenterologist to conduct a second review in July 2024, by which time the surgeon had already been suspended from major operative work. It is important to note that in a clinical governance meeting in February 2024 (ie before either of these structured judgement reviews) it was noted that there were “no learning points identified” in relation to Mr ME’s case. In the case of Mr MR, a structured judgement review took place conducted by a consultant surgical colleague. This report was poor and the coroner wrote to the Chief Medical Officer about it after the inquest. It has the look of the briefest of reviews and tick box exercises. Again, all of the management is referred to as “good”. Mr MR’s case was not discussed during the March 2024 morbidity and mortality meeting, despite the fact that a later death (Lorraine Parker’s, on 30 March 2024) was discussed then. Mr MR’s case did not go to a morbidity and mortality meeting discussion until May 2024. The reasons for this remain unclear. In Lorraine’s case, there was a morbidity and mortality meeting discussion in March 2024 (or perhaps shortly thereafter). The April clinical governance meeting minutes refer to Lorraine’s case and again state “no learning points”. None of these three cases has been the subject of a detailed PSIRF report. Matters of concern On the evidence from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well. Evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings. There is delayed escalation of concerns. Structured judgement reviews are at best, poor, and at worst, defensive. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable. The coroner is concerned about whether the trust has done enough to deal with the concerns about this particular surgeon, not just in the Berkshire area, but more widely.- Posted
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Coroner expresses concerns over NHS menopause care after death of teacher
Patient Safety Learning posted a news article in News
A coroner has expressed wide-ranging concerns about how the NHS cares for women during menopause after the death of a 54-year-old teacher who killed herself after a decline in her mental health. Jacqueline Anne Potter took her own life during overnight leave from an acute psychiatric unit in Somerset where she was being looked after because of mental health issues exacerbated by menopause. In a prevention of future deaths report, senior coroner Samantha Marsh said she was concerned about the “lack of importance” given to menopausal care available on the NHS. She said: “Women who are not fortunate enough to be able to access private clinics and facilities may not be able to access the services and expertise they need at a very crucial transitional phase in their lives. Menopause is not a lifestyle choice, it is an unavoidable part of a woman’s natural biological cycle.” The coroner said: “Given her presentation it would appear that her underlying anxiety had been slowly building; possibly since 2008 but much more so since 2017.” She started HRT but in September 2022 declined again and the following month agreed to a voluntary admission to an acute psychiatric unit after she was found wandering in traffic. She was detained there under the Mental Health Act. Last month an inquest jury concluded that Potter’s death was suicide and said menopause “contributed to her mental health decline and exacerbated her underlying anxiety”. The jury also said that her family “did not receive appropriate information to assist them in keeping Anne safe for an overnight stay”. Read full story Source: The Guardian, 29 April 2025- Posted
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‘Immobile’ patient dies after discharge with no care package
Patient Safety Learning posted a news article in News
An “immobile” patient was found dead after a trust discharged him home with no support and no means of calling for help, a coroner has found. Samuel Brookes, who lived alone, was taken home from Russells Hall Hospital, run by The Dudley Group Foundation Trust, and left in his bed without access to his alarm or mobile phone. John Ellery, the coroner for Shropshire, Telford and Wrekin, said in a Prevention of Future Deaths report sent to the hospital: “Mr Brookes was left unattended for two weeks until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall… When Mr. Brookes got into difficulty he could not raise the alarm or call for help.” The coroner found the hospital had sent Mr Brookes home “without rearranging his required care” and there was “no record or documentation or process to show or demonstrate that the care had been rearranged”. Read full story (paywalled) Source: HSJ, 28 April 2025 -
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Prevention of Future Deaths Report: Samuel Brookes (23 April 2025)
Mark Hughes posted an article in Coroner reports
Samuel Brookes was discharged home from Russells Hall Hospital, Dudley, on the 8 April 2024 where he had been admitted following a fall and long lie at home. The hospital arranged his transportation without rearranging his required care of two carers, four times a day. Mr Brookes, who was immobile and lived alone, was transported to his bed where he could not reach his pendant alarm nor his mobile phone, which was in another room. Mr Brookes was left unattended for two weeks, until on the 22 April 2024 his grandson attended and found him unresponsive, wedged between his bed and the bedroom wall. An ambulance was called, sadly on arrival paramedics confirmed that Mr Brookes was deceased and his death was declared at 11:37 hours. The Coroner in his report highlighted the following matters of concern: The hospital arranged for Mr Brookes transportation home without rearranging the required care. There was no record or documentation or process to show or demonstrate that the care had been rearranged. The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help.- Posted
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Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths and will update delegates on the death certification reforms which came into force in September 2024. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss learning from deaths which is now being extended to all non-coronial deaths wherever they occur and will provide a practical guide to learning from deaths and improving practice in your service. The conference will also update delegates on the National Patient Safety Incident Response Framework (PSIRF) and the implications for patient safety incident investigation and learning from deaths. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email [email protected] Follow on X @HCUK_Clare #LearningFromDeaths hub members receive a 20% discount. Email [email protected] for discount code.- Posted
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On 9 November 2019, a woman who was pregnant with Ida, attended the Royal Lancaster Infirmary Labour Ward in early labour. Ida was a normal child whose death was caused by a lack of oxygen during her delivery. This occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress and contributed to by the lead midwife‘s wholly incompetent failure to provide basic neonatal resuscitation for Ida during the first 3 1/2 minutes of her life that further contributed to Ida’s brain damage. Ida died on 16 November 2019 at the Royal Preston Hospital neonatal intensive care unit. The inquest was one in which Article 2 was fully engaged as a result of the Trust’s clinical governance arrangements, inadequate investigations, a lack of transparency and openness, a failure to respond to a detailed complaint letter, a failure to comply with the Duty of Candour, disputing the findings of the Secretary of State for Health’s independent review panel (HSIB now MNSI), failing to notify external monitoring bodies and failing to comply with internal protocols. The Trust’s lack of compliance with clinical governance requirements in the investigation into Ida’s death had significant similarities with the criticisms made in 2015 of the Trust as set out in The Report of the Morecambe Bay Investigation, otherwise known as the Kirkup Report. [REDACTED] who gave evidence at the inquest, expressed the view that there was a deep seated and endemic culture of defensiveness in respect of maternity incidents at the Trust. [REDACTED] also said that the investigation showed elements of failing to identify significant care issues, brevity, defensiveness and was conducted by unskilled investigators. Matters of Concern A: Culture of Candour [Trust, ICB and DHSC] 1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Dury of Candour. 2. [REDACTED]’s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn. [REDACTED]’s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest. 3. The Trust’s approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day. 4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust’s internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust’s Patient Safety Summits .The matter was reported to the Coroner a year after Ida’s death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”. 5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to [REDACTED] and [REDACTED]’s 1 June 2020 complaint. Together with the Trust’s failure to categorise Ida’s death as only “Moderate Harm” (see point 4 above) cause me also to have concern about the reliability of Trust’s data. B: Clinical Governance and Maternity Governance [Trust, ICB and DHSC] 6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care. 7. As a result of the Trust’s deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust’s clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self- congratulation. The clinicians’ reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence. This approach caused additional distress to the family who had to sit through an extended court hearing to address these issues 8. [REDACTED] is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust’s acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, [REDACTED] is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case. 9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust. 10. The Trust’s clinical governance capability has been the subject of repeated and often severe criticism in the Flynn Review 2009, Fielding Report 2010, Central Manchester Hospital Report 2011, Price Waterhouse Cooper 2012 and Kirkup Report 2015. [REDACTED] in his evidence to the inquest said that the Trust focus on process, which means that you can comply with the process requirements and still produce an inadequate investigation, rather than focussing on outcome, which measures the quality of the investigation and the patient experience. [REDACTED] noted that the Trusts culture impeded transparent and open investigation. I am told that the Trust now uses the PSIRF model and is to appoint 3 whole time equivalent Response Leads by 30 September 2025. However, I remain concerned that the Trust has not fully engaged with the duty of candour such that I am not satisfied that the work on PSIRF to date has truly addressed the issues in respect of Trust’s investigations. C. Mandatory Training, expired training and remedial training [Trust and ICB] 11. The Band 5 midwife supporting [REDACTED] in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as [REDACTED] had not completed her mandatory training. 12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. 13. There was no remedial training was put in place for either the midwives involved in Ida’s delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for [REDACTED], [REDACTED], [REDACTED] and [REDACTED]. D. Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling [Trust, ICB, DHSC, NHSE, [REDACTED]] 14. The Trust graded Ida’s level of harm as “moderate”, even after her death. This grading should have been adjusted to “severe” by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia. 15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone, clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery. 16. [REDACTED] confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour. E: Funding for MSNI [DHSC and [REDACTED], NHSE and ICB] 17. But for the HSIB investigation report into Ida’s death [REDACTED] admitted that Ida’s death due to failures by the Trust would never have come to light or resulted in an inquest. 18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children. 19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida’s will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.- Posted
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NHS hospital too slow to treat doctor’s son who died of sepsis, coroner rules
Patient Safety Learning posted a news article in News
A hospital failed to treat the son of one of its consultants with antibiotics and fluids with the required urgency hours before he died of sepsis, a coroner has ruled. It was unclear whether mistakes and delays in the treatment of William Hewes, 22, on 21 January contributed to his death, the coroner, Mary Hassell, said. The death of Hewes raised similar issues to the death of 13-year-old Martha Mills in 2021, Hassell said. Martha’s death led to the adoption of Martha’s rule, which gives families the right to a second opinion on medical treatment. Hewes, who was studying politics and history at Leeds University, died of meningococcal septicaemia at Homerton hospital in east London, where his mother, Dr Deborah Burns, was a consultant paediatrician. Burns told the inquest she had been unable to work at the hospital since her son’s death because of feelings of “betrayal” towards colleagues who ignored her warnings about his treatment. Burns repeatedly asked medics to administer lifesaving antibiotics in the vital first hour of his treatment. But antibiotics were not given until 1.25am due to a misunderstanding between a doctor and nurses, the inquest at Bow coroner’s court heard. There was also a delay of about 90 minutes in transferring Hewes from the resuscitation area of A&E to the intensive care unit amid a disagreement between medics about escalating his care. The hospital admitted these mistakes were “suboptimal”. Hassell said Hewes was not treated “with the urgency he should have been” but added: “It is unclear whether, if he had been administered all appropriate treatment promptly, his life would have been saved.” She said she would issue a prevention of future deaths report to Homerton hospital on the basis that the work it had done since Hewes’s death should be shared nationally. Read full story Source: The Guardian, 27 March 2025- Posted
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Teen died from asthma attack after she was wrongly discharged from hospital
Patient Safety Learning posted a news article in News
A coroner has voiced serious concerns over a recurring "lack of observations" at London's Royal Free Hospital following the death of a teenager. Sixteen-year-old Billie Wicks died after suffering her first ever asthma attack. Her parents rushed her to the Hampstead hospital on 17 September last year, but a new report reveals the A&E department was "understaffed" that night. The coroner's concerns highlight a potential systemic issue at the hospital regarding patient monitoring. Senior coroner for Inner North London, Mary Hassell, said that Billie should have had routine checks, or observations, taken every hour. If she had these observations, then medics would have recognised the severity of Billie’s illness, Ms Hassell said. “Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived,” she wrote in a prevention of future deaths report. “Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. “That senior medical review would have changed the course of her management and saved her life.” Read full story Source: The Independent, 18 March 2025- Posted
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On 17 September 2024, Edwin Buckett, commenced an investigation into the death of Billie Wicks aged 16 years. The investigation concluded at the end of the inquest on 6 March 2025. Billie had been brought to the Royal Free Hospital just before midnight the night before her death with an asthma attack. A first presentation of asthma at the age of 16 years without any family history is unusual, and it was a busy night in the accident and emergency department. Billie was inappropriately discharged at approximately 3.30am without adequate repeat observations or senior clinical review, and so her asthma was not diagnosed or treated. If it had been, she probably would have survived. The MATTERS OF CONCERN are as follows: On the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations. Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need. I heard that Billie was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction. In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).- Posted
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Early Day Motion - National oversight mechanism (27 February 2025)
Mark Hughes posted an article in Coroner reports
This is an Early Day Motion tabled in the House of Commons on 27 February 2025, which urges the Government to also create a national oversight mechanism to ensure that recommendations concerning deaths involving the State and corporate agencies are routinely monitored by an independent body to help enact learning and prevent future deaths. What is an Early Day Motion? Early Day Motions are motions submitted for debate in the House of Commons for which no day has been fixed, and as such very few are debated. They are used to put on record the views of individual MPs or to draw attention to specific events or campaigns. By attracting the signatures of other MPs, they can be used to demonstrate the level of parliamentary support for a particular cause or point of view. Early Day Motion 867: National oversight mechanism This Early Day Motion was sponsored by Carla Denyer MP. It reads as follows: That this House believes that the State owes it to bereaved families and victims to learn and implement lessons from deaths involving the State and corporate agencies; notes that the Grenfell Inquiry recognised a failure of the State to follow up on recommendations made by inquests and inquiries; acknowledges the Government’s commitment to a publicly available record of these recommendations as a step in the right direction; urges the Government to also create a national oversight mechanism to ensure that these recommendations are routinely monitored by an independent body to help enact learning and prevent future deaths; further notes that such a Mechanism would go beyond facilitating transparency and ensure accountability, which is desperately needed for bereaved families and for public confidence; and believes that for victims of large scale tragedies such as Hillsborough and Grenfell, as well as victims of individual state failings, the Government must ensure that lessons are learned from their deaths and the same mistakes are not repeated. Related reading Inquest - No More Deaths Campaign Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS- Posted
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A coroner has issued a warning about the role of physician associates in NHS hospitals after a woman with severe abdominal problems was wrongly diagnosed as having a nosebleed and died four days later. The family of Pamela Marking, 77, were under the mistaken impression she had been seen by a doctor when she was examined in an emergency department, rather than a physician associate (PA) with far less training. Surrey assistant coroner Karen Henderson has written to 12 health leaders or bodies including the UK health secretary, Wes Streeting, and NHS England expressing concerns about the “limited training” PAs have and the lack of public understanding about their roles. In a prevention of future deaths report, Henderson said Marking was taken to East Surrey hospital in Redhill on 16 February last year after she vomited blood-stained fluid and had a tender abdomen. The coroner said the PA who saw her had “a lack of understanding of the significance of abdominal pain” and sent her home the same day. Marking deteriorated, returning to the hospital two days later. She underwent surgery for complications arising from a femoral hernia but died on 20 February 2024. Henderson said the PA had acted independently in the diagnosis, treatment, management and discharge of Marking without independent oversight by a medical practitioner. The coroner said: “Given their limited training and in the absence of any national or local recognised hospital training for physician associates once appointed, this gives rise to a concern they are working outside of their capabilities.” Read full story Source: The Guardian, 27 February 2025 Related reading on the hub: Physician associates: What are the patient safety issues? An interview with Asif Qasim Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates Prevention of future deaths report: Susan Pollitt (8 August 2024)- Posted
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Prevention of Future Deaths Report: Pamela Marking (24 February 2025)
Sam posted an article in Coroner reports
On 16 February 2024, Pamela Anne Marking – who was unable to give a complete history due to cognitive issues – was admitted to the Emergency Department at East Surrey Hospital from her home address after unknowingly vomiting blood-stained fluid, with right sided and suprapubic abdominal tenderness. She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia. Mrs Marking re-presented to the Emergency Department two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia containing ischaemic bowel requiring emergency surgery later that evening. Despite maximal support Mrs Marking died at East Surrey hospital on 20th February 2024. The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death. The medical cause of death given was: 1a Respiratory failure and Sepsis 1b Aspiration of feculent gastric contents at induction of anaesthesia 1c. Strangulated femoral hernia. Coroner's concerns 1. The term ‘Physician Associate’ is misleading to the public. Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners. 2. Lack of public understanding of the role of Physician Associate. Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety. 3. The right of patients and family to seek a second opinion. The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor. 4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate. A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed, this gives rise to a concern they are working outside of their capabilities. 5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates. Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner. This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety. 6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery. Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice. 7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI. Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4). 8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic. Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.- Posted
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It was in a coroner’s court last year, at the inquest into the death of his 27-year-old daughter Maeve, that Sean O’Neill heard the most dispiriting words. The coroner, Deborah Archer, said she was going to write a prevention of future deaths (PFD) report, highlighting to the NHS and other agencies areas of concern. Then she added: “I write a lot of these reports, and often nothing happens.” Maeve died after suffering for half her life with myalgic encephalomyelitis (ME), a post-viral condition that is not well understood, inadequately researched and which doctors often refuses to recognise or treat. Sean's aim was to use the media to highlight what happened to Maeve and raise awareness of the plight of the hundreds of thousands of people whose lives are limited by ME and similar conditions. His second aim was to convince the coroner to write a PFD report and point out areas in healthcare, medical research, education and training where action could be taken that might prevent further such deaths. The written responses to Archer’s PFD report have been underwhelming. The public health minister, (the recently resigned) Andrew Gwynne, promised an NHS delivery plan. NHS England said it would do a “stocktake” of ME services, even though there had been evidence at the inquest that such services are scarce, and in the cases of severely ill patients, “non-existent”. The Medical Research Council said it “recognises the unmet clinical need for better diagnosis and treatments for people living with ME” but defended its record to date. In 2023 there were more than 1,600 inquests that had been open for more than two years; often these are the most difficult cases, yet bereaved families face being repeatedly traumatised by every preliminary hearing and legal letter. As in Maeve’s case, the best hope for a family is that a PFD report points the way to reform. A coroner is not allowed to recommend, only suggest. Yet only rarely are these reports written. Those coroners who do write reports often find their suggestions ignored. Just under 40% of the 5,532 PFD reports published since 2013 have received no responses. There is no other section of the legal system in greater need of reform. There should be a national coronial service, more PFD reports should be written and lessons should be disseminated. What is the point of investigating avoidable deaths — of making bereaved families relive their trauma, of spending millions of public pounds — unless we are prepared to learn how to avoid similar fatal errors? Read full story (paywalled) Source: The Times, 23 February 2025- Posted
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Thomas Kingston's family calls for antidepressant prescription change
Patient Safety Learning posted a news article in News
The parents of Thomas Kingston have warned about the side effects of antidepressants after he took his own life. Mr Kingston died from a head injury in February last year at his parents' home in the Cotswolds. A gun was found near his body. The 45-year-old had stopped taking his medication, which had been prescribed by a GP at the Royal Mews Surgery in the days leading up to his death. His parents, Martin and Jill Kingston, are now calling for a change in how patients are prescribed selective serotonin reuptake inhibitors (SSRI) - a widely used type of antidepressant. Martin Kingston told BBC Radio 4's Today programme he believes both the patient and the people close to them should be told more explicitly about the potential side effects of the medication, including what can happen if they stop taking it. The couple want patients to sign a document confirming they've been told about the difficulties of going on and coming off the medication. This could include the patient being told that "it's an extreme case, but it could lead to suicide", Mrs Kingston says. "We'd really like to see that a person, a spouse, a partner, a parent, a close friend, somebody, was going to walk with them through it. Maybe they should be at that signing time." Recording a narrative conclusion at an inquest into his death in December, Katy Skerrett, senior coroner for Gloucestershire, said Thomas Kingston had taken his own life. "The evidence of his wife, family and business partner all supports his lack of suicidal intent," she said at the inquest. "He was suffering adverse effects of medication he had recently been prescribed." In a prevention of future deaths report, made in January, Ms Skerrett said action must be taken over the risk to patients prescribed SSRIs. She questioned whether there was adequate communication of the risks associated with such medication. Read full story Source: BBC News, 4 January 2025 Related reading on the hub: The question that will save lives: Interview with Katinka Blackford Newman, founder of Antidepressant Risks Long-lasting sexual dysfunction after taking antidepressants: Lack of recognition harmful to patients Post-SSRI Sexual Dysfunction: After 30 years, why is the health system still failing to recognise this life-limiting adverse effect?- Posted
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Mr Thomas Henry Robin Kingston was a 45 year old man who was visiting his parents in Kemble Gloucestershire for the weekend. He had recently been experiencing anxiety, but had not expressed any suicidal ideation. On Sunday 25 February 2024 after lunch he began to unload his car, and prepared to return to London. Between approximately 1700-1800 hours he removed a shotgun from his vehicle which he had recently borrowed from his father for a shoot. He then accessed an annex attached to his parent’s property. Within a locked bathroom he self inflicted a gun shot to the head, and sustained injuries incompatible with life. He was subsequently found by his father. He was pronounced deceased at 1854 hours by attending police, who confirmed there were no suspicious circumstances surrounding his death. Intent remains unclear as the deceased was suffering from adverse effects of medications he had recently been prescribed. The medical cause of death was 1A Traumatic wound to head. Matters of Concern Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced.- Posted
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Systemic issues identified within mental health services
Patient Safety Learning posted a news article in News
A new report from the Health Services Safety Investigations Body (HSSIB) has shed light on significant systemic issues within mental health services, highlighting a persistent culture of fear and blame, and a lack of patient and family involvement, which obstruct effective learning from inpatient deaths. The HSSIB report scrutinises how mental health providers learn from deaths occurring in inpatient units and within 30 days post-discharge. The investigation reveals multiple processes involved in learning from deaths, including the Learning from Deaths Framework, coroner's inquests, and investigations following patient safety events. The report indicates that there are substantial challenges in maintaining safety, conducting effective investigations, and ensuring system-wide learning. It identifies that investigations and patient safety event analyses, although intended to promote transparency and learning, often suffer from variable quality. Local investigations frequently lack comprehensive information and fail to observe clinical work practices in real-time, hindering a complete understanding of care delivery. A critical revelation of the investigation is the prevalent culture of blame within mental health services. Patients, families, and organisations often fear safety investigation processes, which are perceived as punitive rather than educational. The report underscores that patient safety investigations rarely account for the emotional distress experienced by those involved, leading to compounded harm. Read full story Source: National Health Executive, 30 January 2025- Posted
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A coroner has ordered an integrated care board to fill gaps in its services and address mental health bed shortages following the death of a 29-year-old with autism and ADHD who spent 26 days in A&E. Matthew “Matty” Sheldrick (they/them), who identified as non-binary, died from self-ligature outside Royal Sussex County Hospital after returning to A&E one month on from the 26-day stay. Matty had struggled to access community services for support with their mental health, autism, and ADHD. Confusion about and delays to appointments during their time in hospital and the community contributed to a sense of hopelessness, according to Matty’s mother, Shelagh Sheldrick. In two prevention of future death reports published last month, senior area coroner Penelope Schofield said Matty received “no meaningful therapeutic input” during their prolonged first stay in an A&E short-stay ward and that the environment “contributed to the deterioration of their mental health difficulties”. In a report addressed to Sussex Integrated Care Board, Ms Schofield raised concerns over a lack of funding for private mental health beds for autism patients, and the fact that oversubscribed public providers “very often” rejected referrals for autism patients because of “additional risks”. Read full story (paywalled) Source: HSJ, 28 January 2025- Posted
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