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News Article
Birmingham hospital faces criminal probe after death of vulnerable man
Patient Safety Learning posted a news article in News
A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead t -
News Article
Trust failed for months to give vital medication to vulnerable inmate
Patient Safety Learning posted a news article in News
A troubled NHS trust failed for months to give vital medication to a prison inmate who had a long-standing diagnosis of HIV, an inquest has found. A jury at Essex Coroner’s Court concluded that a series of failures and neglect by Essex Partnership University Trust (EPUT) contributed to the death of Thokozani Shiri in April 2019. The 21-year-old spent two spells as a prisoner at HMP Chelmsford, where EPUT provided some services at the time. He was considered vulnerable due to a long-standing diagnosis of HIV for which he was receiving treatment before he went to prison, and the t -
News Article
Man's bed death was avoidable, says coroner
Patient Safety Learning posted a news article in News
The death of a retired police officer who got his head trapped in a hospital bed was an avoidable accident, an inquest has concluded. Max Dingle, 83, of Newtown, Powys, died after he became stuck between the rails and mattress at the Royal Shrewsbury Hospital on 3 May 2020. The initial post-mortem test gave the cause of death as heart disease. But a second examination, commissioned by Mr Dingle's son, found entrapment and asphyxiation to be the cause. After comparing and discussing their findings, both pathologists then agreed "entrapment did play a significant part in the -
News Article
Ambulance trust covered up paramedics’ fatal errors like a ‘criminal gang’
Patient Safety Learning posted a news article in News
An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up. Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown. “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everythi -
Content ArticleCoroner's concerns The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be a
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Content Article
Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)
Sam posted an article in Coroner reports
Coroner's concerns Without changes in the NHS Pathway the 111 call handlers will not be adequately assisted by the Pathways to recognise the acutely unwell child, in particular: at the time of the conclusion of the inquest, there was no question within the NHS Pathways questionnaire concerning cold hands and feet for children aged over five at the time of the conclusion of the inquest, the question regarding green vomit, asked in respect to children over five, had an inappropriately high threshold (that is required severe pain for more than four hours before the question was -
Content ArticleMatters of Concerns: Children-particularly small infants do not present like adults when they are very unwell. Nor can they articulate their symptoms in a way that lends itself to prescribed pathway questions and answers and they are not in front of the staff handling the calls who therefore rely on parents for information. Whilst since this event there have been steps to provide training of staff at 111 and Out of Hours services and NHS Digital have reworked the pathways to deal with multiplicity of symptoms there are still concerns re what further steps may be taken regrading cases invo
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News Article
Blackpool death: Abortion sepsis risk training inadequate
Patient Safety Learning posted a news article in News
Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to -
Content ArticleMatter of concerns: Inadequate training of doctors and other medical professionals re the risk of sepsis following Early Medical Terminations. Evidence from a wide range of clinicians who had cared for Sarah in March and April 2020 echoed each other. The clinician evidence revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following Early Medical Termination. The hospital trust accepted that at the time of Sarah’s death, there was confirmat
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Content ArticleCoroner's concerns There were excessive delays in handing over patients at hospital. The West Midlands Ambulance Service Serious Incident report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands.
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News ArticleHeart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in Mar
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News Article
‘Staff holidays’ delay death review by up to nine months
Patient Safety Learning posted a news article in News
A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’. An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”. She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “ca -
Content ArticleThe Matters of Concern are as follows: For the Priory Hospital: 1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. There are serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost. 2. Record Keeping quality: The
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News Article
‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery
Patient Safety Learning posted a news article in News
"I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes. Eight weeks later, Brooke took her own life. The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to he -
Content ArticleBrooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to
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News Article
Care home resident died after unqualified nurse administered wrong medication
Patient Safety Learning posted a news article in News
A nurse with no qualifications gave a care home resident a fatal dose of the wrong drug, leading to her death before she then tried to cover up her mistake. Katherine Hutchinson gave Fiona Jayne Thorne a fatal overdose of a powerful anti-psychotic drug, which was meant for another patient, an inquest heard. She then tried to cover up her errors which contributed to the death of the 36-year-old with learning difficulties, Derbyshire Live reported . Ms Hutchinson had, at the time, been the nurse in charge at Whitwell Park Care Home, in Whitwell, Derbyshire despite not having any q -
News Article
NHS trust apologises over death of woman, 27, after cancer misdiagnosis
Patient Safety Learning posted a news article in News
An NHS trust has apologised over the death of a 27-year-old events manager after a locum gynaecologist mistook aggressive cervical cancer for a hormonal or bowel problem. The family of Porsche McGregor-Sims, who died a day after being admitted to Queen Alexandra hospital in Portsmouth, told her inquest that she had felt she was not listened to and that the misdiagnosis had robbed them of a chance to say goodbye. The area coroner Rosamund Rhodes-Kemp said the case was one of the most “shocking and traumatic” she had dealt with and she would write to Portsmouth hospitals university NHS -
Content Article
Learning from Coroner's reports
Patient Safety Learning posted an article in Coroner reports
What are PFD reports? Coroners have a duty to decide how somebody came by their death and also, where appropriate, to report about that death with a view to preventing future deaths.[1] [2] These reports follow a set template format and are issued by the Coroner to any person or organisation where, in their opinion, action should be taken to prevent future deaths. These reports are made publicly available online and the persons/organisations involved having a duty to respond within 56 days. PFD reports relating to deaths in health and social care settings can help to identity what wen- Posted
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News Article
Transgender teenager's death preventable, coroner says
Patient Safety Learning posted a news article in News
The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people ex -
Content ArticleCoroner's Matters of Concern The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. Although I unde
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News Article
Man's partner 'begged' for help before his death
Patient Safety Learning posted a news article in News
A man who died from a mixed medication overdose might still be alive if the help his partner was "begging" for had been provided, a coroner said. Mental health patient Benjamin Stroud, 42, had been under the care of Essex Partnership University NHS Trust (EPUT) in the weeks before his death in March. Essex coroner Michelle Brown said in a post-inquest report that, despite "escalating psychosis", his care co-ordinator did not flag the case. Following an overdose of medication in February, his partner, a nurse, called for psychiatric intervention and despite "begging" for help, Mr -
Content ArticleMr Stroud had been admitted from A&E under section 2 of the Mental Health Act between the 16 and 24 January 2021, to the Lindon Centre. He was then released under the ambit of The Gables and had been seen by a psychiatrist whilst under section 2. This appeared from the evidence to be the only time he was seen by such a person. On the 22 February 2021, he took an overdose of insulin; however, as his partner is a nurse, he didn’t attend hospital as she knew what to do. A PSIIR report and action plan was completed. Mr Stroud’s partner gave evidence, and it was clear from her account that
