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Found 42 results
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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 4.
  6. 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
  7. 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
  8. News Article
    Beth and Dan Wankiewicz want answers about why their baby son Clay died last year, shortly after his birth at Doncaster Royal Infirmary. Despite a low-risk pregnancy, the family say Clay died from multiple skull fractures. Doncaster and Bassetlaw NHS Foundation Trust said "the provision and delivery of high-quality" care is a priority. The BBC has found a 2016 review flagging concerns about the hospital's maternity care was never published. The report - one of scores of unpublished reports discovered by a Freedom of Information request by BBC's Panorama programme - highlighted signif
  9. 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
  10. 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
  11. Content Article
    Coroner, Emma Serrano, concluded in the coroner's report that transplant patients are put on strong immunosuppressive medication to prevent rejection of the transplanted organ. The medication, tacrolimus in Jamie Lee Pools case, has a common known side effect of reducing magnesium levels within the body. This can be life threatening. Despite this, it is not standard practice to regularly test transplant patients magnesium levels. Whilst the Trust providing care for Jamie Lee Poole, has now remedied this, and routinely test posttransplant patients’ for magnesium levels, this is not the cas
  12. Content Article
    Prevention of Future Deaths report – Brian Button Response from the Royal Sussex County Hospital
  13. 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
  14. 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
  15. Content Article
    The following concerns are highlighted in the report: Inadequate training of doctors and other medical professionals re eating disorders. Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk anorexia nervosa patients by primary or secondary care providers. Lack of robust and reliable data regarding the prevalence of eating disorders. The impact of the COVID 19 pandemic.
  16. News Article
    Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to
  17. 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
  18. 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
  19. 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
  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. 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
  22. 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
  23. 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
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