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Found 48 results
  1. News Article
    Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip rep
  2. Content Article
    In this report, the Coroner states their concerns as follows: No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Heath NHS Trust since 2018, there remains no requirement to utilise such a tool. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient's welfare passed between the two teams but no targeted que
  3. News Article
    A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by E coli infection, an inquest has found. Coco Rose Bradford was taken to the Royal Cornwall hospital in the summer of 2017 suffering from stomach problems and later transferred to the Bristol Royal hospital for children, where she died. The following year an independent review flagged up failings in her care in Cornwall and the Royal Cornwall hospitals trust apologised for how it had treated her. Her family were left with the belief she had died of sepsis and could have
  4. News Article
    Coroners in England are demanding changes in a series of reports highlighting how the struggling healthcare system’s responses to the pressures of the COVID-19 pandemic contributed to patients’ deaths. Coroners are obliged to write a report recommending action in any cases where they believe that this is necessary to prevent future deaths. Reports now emerging suggest that factors in deaths during the pandemic include the move by GPs to telephone consultations, the requirement for vulnerable patients to attend hospital appointments alone, and the lack of safeguards for patients in care ho
  5. Content Article
    Mrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered. Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to re
  6. News Article
    Failings by NHS 111 contributed to the death of an autistic teenager, a coroner has ruled. Hannah Royle, 16, suffered a cardiac arrest as she was driven to hospital by her parents after a 111 algorithm failed to notice she was seriously ill. A coroner said her death had exposed a risk people were being misled about the capability of the system and its staff. An NHS spokesperson said it would act on the findings and learnings "where necessary". Hannah's father Jeff Royle said he regretted dialling 111 and wished he had taken his daughter straight to hospital. "I feel so
  7. News Article
    An inquest into the death of a London bus driver at London’s Nightingale Hospital during the first wave of coronavirus has heard evidence about equipment mistakes which may have harmed patients. Kishorkumar Patel, aged 58, was one of the first patients to be admitted to the field hospital at London’s Excel Conference Centre in April last year. An inquest at East London Coroner’s Court was told doctors and nurses were forced to work “leanly” because of limited staff and ventilators to help patients breathe. Mr Patel is one of 10 patients who had the wrong filter used on the venti
  8. News Article
    The health service ombudsman has warned he will ‘be in no position to investigate’ the behaviour of another watchdog under the government’s health service reforms. Rob Behrens, the Parliamentary and Health Service Ombudsman, said plans to create a “closed safe space” for the information provided by clinicians to the Healthcare Safety Investigation Branch (HSIB) will mean a reduction in his powers and he will not be able to hold HSIB to account. Mr Behrens, speaking at HSJ’s Patient Safety Congress, said that although coroners would be able to access information gathered by HSIB inves
  9. Content Article
    While under continual cardiac monitoring from the 6– 8 March 2021, Ann Geraghty experienced two periods of ventricular standstill which were recorded but missed. Had these been detected she would have been admitted into a Critical Care Unit, though the Coroner noted that her subsequent cardiac arrest could not have been prevented. The Coroner raises concerns that: The Philips central monitoring station used by the hospital detected the two periods of ventricular standstill but its alarm notification self-terminated when the heart rhythm had corrected. Following the Trust’s i
  10. News Article
    Shortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer has revealed, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision. The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”. Coroners issu
  11. Content Article
    In 2020, 4,561 deaths related to drug poisoning were registered in England and Wales (equivalent to a rate of 79.5 deaths per million people); this is 3.8% higher than the number of deaths registered in 2019 (4,393 deaths; 76.7 deaths per million). A worrying statistic, which the Transform Drugs Policy Foundation describes as #50YearsOfFailure: "For over 50 years, the war on drugs has caused injustice, suffering and tragedy to communities across the world. It's time to bring it to an end." In summary there were a record 2996 drug-related deaths in 2020: opioid deaths up
  12. News Article
    New figures has revealed serious incidents have occurred in NHS trusts where the wrong bodies of patients were released to families or lost, damaged or kept the organs or bodies of babies without family permission. According to data from the Human Tissue Authority, these incidents have reduced over the years, however, the errors still affected more than 100 families in the latest year to March 2021. Incidents such as these are extremely distressing for the friends and family of the deceased patient, but also for the staff working in the mortuaries involved, who try their best to uphold th
  13. News Article
    There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said. Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county. Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected". She said she was reassured the health board had taken steps to improve care. Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July
  14. News Article
    A national safety watchdog has been forced to release almost 100 pieces of evidence, including names of NHS staff, after being ordered to by courts. A freedom of information request, submitted by HSJ, has revealed the Healthcare Safety Investigation Branch (HSIB) has been required to release 93 interviews with staff, family members and external experts, along with their identities, over the last two years. The interviews, which relate to HSIB investigations involving hospital trusts across England, were released to coroner’s courts through eight separate orders dating from February
  15. Community Post
    Hi 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
  16. News Article
    The parents of a baby who died after medical errors are to push for a new inquest into his death, after they say a "cruel" inquest denied them justice. Hayden Nguyen died in 2016 after medics failed to treat an infection properly. However, despite the NHS trust admitting mistakes, coroner Shirley Radcliffe concluded the infant died of natural causes, after raising concerns about the hospital's initial investigation. Hayden was six days old when his parents took him to the Chelsea and Westminster hospital in west London in August 2016. He initially had a fever but rapidly deteriorated
  17. News Article
    An NHS trust has admitted failing to provide safe care and treatment for a mother and her baby boy, who died seven days after an emergency delivery. Mother Sarah Richford said it brought "some level of justice" for baby Harry's death in 2017. Lawyers for the East Kent Hospitals Trust pleaded guilty to the charge at Folkestone Magistrates Court. The trust said it had made "significant changes" and would "do everything we can to learn from this tragedy". Mrs Richford said: "Although Harry's life was short, hopefully it's made a difference and that other babies won't die". Sh
  18. Content Article
    The 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
  19. Content Article
  20. News Article
    Former patients of rogue breast surgeon Ian Paterson may have died of “unnatural deaths” two senior coroners have said. Senior coroner for Birmingham and Solihull, Louise Hunt, and area coroner Emma Brown have said they believe there is evidence to suspect victims of Ian Paterson, who was jailed for 17 counts of wounding with intent in 2017, died unnaturally as a result of his actions. They now plan to open four inquests into the deaths of patients who died from breast cancer after being treated by Paterson. “Following preliminary investigations, the senior and area Coroner beli
  21. News Article
    Coroners have warned the NHS nearly a dozen times in recent years that a lack of imaging capacity could lead to more deaths, HSJ can reveal. Five of these warnings followed deaths at a single site, Tameside General Hospital in Greater Manchester. The most recent case concerned a patient that died after developing covid during a prolonged wait for an MRI scan. Sir Mike Richards last year warned in a major report for NHS England about the lack of imaging equipment, and the Royal College of Radiologists has highlighted national shortages of radiology staff on numerous occasions in recen
  22. Content Article
    The web page includes information on: Which deaths are reported to the coroner What happens next after a death is reported About identifying the body Coroner liaison officers Post mortem examinations Post mortem results Returning the body Funeral arrangements Inquests
  23. Content Article
    What 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
  24. News Article
    Inquests into coronavirus deaths among NHS workers should avoid examining systemic failures in provision of personal protective equipment (PPE), coroners have been told, in a move described by Labour as “very worrying”. The chief coroner for England and Wales, Mark Lucraft QC, has issued guidance that “an inquest would not be a satisfactory means of deciding whether adequate general policies and arrangements were in place for provision of PPE to healthcare workers”. Lucraft said that “if there were reason to suspect that some human failure contributed to the person being infected wit
  25. News Article
    A 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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