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Showing results for tags 'Coroner'.
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News Article
Coroner says student might be alive if GP had seen him
Patient Safety Learning posted a news article in News
A law student who died after four remote GP consultations might have lived had he been given a face-to-face appointment, a coroner ruled. David Nash, 26, died in November 2020 from a bone infection behind his ear that caused an abscess on the brain. Over a 19-day period leading up to his death, he had four phone consultations with his GP. The coroner, Abigail Combes, said the failure to see him meant he underwent surgery ten hours later than it could have been. Andrew and Anne Nash fought for more than two years to find out whether their son would have lived if he had been -
News ArticleAn NHS trust declined to provide care for a vulnerable Black man days before he died in police custody while having a psychotic episode, The Independent has learnt. Godrick Osei, 35, died after being restrained by up to seven Devon and Cornwall Police officers in the early hours of 3 July 2022, after fleeing his flat and hiding in the cupboard of a care home in Truro. His family said he had been expressing “paranoid thoughts” and had called the police himself for help. He was arrested and died within an hour. Mr Osei had been diagnosed with anxiety and depression, had suspected
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News Article
Wales coroner rules nurses’ Covid deaths as industrial disease
Patient Safety Learning posted a news article in News
The deaths of two nurses from Covid-19 in the early days of the pandemic have been ruled as industrial disease. Gareth Roberts, 65, of Aberdare, and Domingo David, 63, of Penarth, were found to have been most likely to have contracted the virus from colleagues or patients while working for hospitals under the Cardiff and Vale University Health Board. The senior coroner Graeme Hughes concluded on Friday that although they were given appropriate personal protective equipment (PPE), Roberts and David were “exposed to Covid-19 infection at work, became infected and that infection caused” -
Content ArticleCoroner's Matters of Concerns Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes. The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others. The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial in
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Content ArticleMrs 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
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Content ArticleCoroner's concerns During the course of the investigation the evidence revealed matters giving rise to concern. If the coroner is inhibited from being in a position to confirm the cause of death of a baby, there is a risk that future deaths will occur unless action is taken. Matters of Concern The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a
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Content ArticleCoroner's Matters of Concerns: Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). There needs to be better education both to doctors and to patients in risk groups to prevent future death. In relation to Pathology: The current
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News Article
Hospital water supply faces bacteria risk
Patient Safety Learning posted a news article in News
A coroner has written to the health secretary warning a lack of guidance around a bacteria that could contaminate new hospitals' water supply may lead to future deaths. It follows inquests into the deaths of Anne Martinez, 65, and Karen Starling, 54, who died a year after undergoing double lung transplants at the Royal Papworth Hospital in Cambridge in 2019. Both were exposed to Mycobacterium abscessus, likely to have come from the site's water supply. The coroner said there was evidence the risks of similar contamination was "especially acute for new hospitals". In a pre -
Content ArticleCoroner's concerns 1 It is recognised that M. abscessus poses a risk of death to those who are immunosuppressed. That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients. To date, 34 patients at Royal Papworth have contracted M. abscessus from the hospital’s water. Cases continue to be reported, albeit at a declining rate. 2 There is an incomplete understanding of how M. abscessus may enter and/or colonise a hospital water system. 3 Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by
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News ArticleWhen David Morganti’s case notes landed on Andrew Cox’s desk this autumn they told a devastating story — but one which was depressingly familiar to the senior coroner for Cornwall. The 87-year-old RAF veteran had fallen and hit his head in the bathroom of the house he shared with his wife, Valerie, in April. It took nine hours for paramedics to reach their home near St Austell, Cornwall. As they waited, the bleeding on his brain became gradually worse until he lost consciousness. By the time he reached hospital it was too late. An expert neurosurgeon told Cox that had he reached hospital
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News ArticleA key national policy change recommended by the inquest which led to the East Kent maternity inquiry will not be implemented until next February – more than three years after it was called for by a coroner. The recommendation – that obstetric locum doctors be required to demonstrate more experience before working – was made in a prevention of future deaths report following the inquest into the death of seven-day-old Harry Richford at East Kent Hospitals University Foundation Trust. The remaining 18 recommendations from the PFD report were requiring specific actions by the trust, rath
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Content ArticleCoroner's concerns and recommendations Concern 1 X was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital. This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. X gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trust
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AvMA case study: Stuart's story
Patient-Safety-Learning posted an article in Risk management and legal issues
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Content Article
AvMA case study: Lyndsey's story
Patient-Safety-Learning posted an article in Risk management and legal issues
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Content Article
AvMA case study - Evadney's story
Patient-Safety-Learning posted an article in Inquests
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Content ArticleCoroner's concerns Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care. The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation. The primary responsibility fell upon the famil
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News Article
Coroner warns of lack of change since man's death
Patient Safety Learning posted a news article in News
A coroner has raised concerns about a mental heath trust where staff falsified records made on the night a man died. Eliot Harris, 48, died in the Northgate Hospital in Great Yarmouth, run by the Norfolk and Suffolk Foundation Trust (NSFT), in April 2020. Norfolk coroner Jacqueline Lake said that, two years on, staff were still not recording observations properly. The 48-year-old, who had schizophrenia, had been sectioned under the Mental Health Act after he became agitated at his care home and refused to take medication. He was taken to Northgate Hospital and, after a period in -
Content ArticleCoroner's concerns Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of obser
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News Article
Coroner criticises NHS trust’s treatment of family of woman who killed herself
Patient Safety Learning posted a news article in News
An NHS trust has “not covered itself in glory” in its dealings with the family of a vulnerable young woman who killed herself after being refused admission to hospital, a coroner has found. The three-day hearing looked at evidence withheld from the original inquest into the death of Sally Mays, who killed herself in 2014 after being turned away from a mental health unit. Mays was failed by staff “neglect” at Miranda House in Hull, a 2015 inquest ruled, after a 14-minute assessment led to her being refused a place, despite being a suicide risk. Her parents, Angela and Andy Mays, -
News Article
Hospital rated ‘inadequate’ after death prompts inspection
Patient Safety Learning posted a news article in News
A private hospital has been rated ‘inadequate’ by a health watchdog following an inspection prompted by a young patient’s preventable death. Woodbourne Priory Hospital, in Edgbaston, has had its overall Care Quality Commission rating downgraded from “good” to “inadequate” after inspectors visited in May. The regulator’s visit was sparked by a prevention of future deaths report into the death of Birmingham University graduate Matthew Caseby, 23, who was placed at the hospital as an NHS-funded patient in September 2020. Mr Caseby had been detained under the Mental Health Act but m
