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Found 17 results
  1. News Article
    A senior coroner has demanded action by Simon Stevens, chief executive of NHS England, to ensure that GPs monitor repeat prescriptions properly, after an 84 year old man with dementia died from an overdose of tramadol. Peter Cole, who was found collapsed at his home in Welwyn in Hertfordshire by a neighbour, had amassed a large quantity of unused prescription drugs at his house. He had numerous drugs on repeat prescription, said Geoffrey Sullivan, chief coroner for Hertfordshire. Read full story (paywalled) Source: BMJ, 5 August 2020
  2. 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 believe there is evidence to have reason to suspect that some of those deaths may be unnatural. In accordance with the Coroners and Justice Act 2009, inquests will now be opened in relation to four former patients of Mr Paterson.” Deborah Douglas, a victim of Paterson who leads a support group in Solihull, told The Independent: "I have spoken to so many women over the years who have since died. This is what I have always known and fought for. "Paterson lied about pathology reports and people did develop secondary cancers." Read full story Source: The Independent, 4 July 2020
  3. News Article
    The coroner investigating the botched birth of a baby boy who died from hypoxia has strongly criticised the Healthcare Service Investigation Branch (HSIB) over its report on his death. Karen Henderson, who conducted the inquest into the death of baby Theo Young in May 2018 at East Surrey Hospital said that the HSIB had asked Surrey and Sussex Healthcare NHS Trust not to undertake its own investigation, “effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths.” Read full story (paywalled) Source: BMJ, 19 May 2020
  4. 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 with the virus”, an inquest may be required. The coroner “may need to consider whether any failures of precautions in a particular workplace caused the deceased to contract the virus and so contributed to death”. But he added: “An inquest is not the right forum for addressing concerns about high-level government or public policy.” Labour warned the advice could limit the scope of investigations into the impact of PPE shortages on frontline staff who have died from COVID-19. “I am very worried that an impression is being given that coroners will never investigate whether a failure to provide PPE led to the death of a key worker,” said Lord Falconer, the shadow attorney general. “This guidance may have an unduly restricting effect on the width of inquests arising out of Covid-19-related deaths.” Read full story Source: The Guardian, 29 April 2020
  5. News Article
    An 87-year-old woman died after her carers gave her the wrong medication, a coroner was told. Heather Planner, from Butler's Cross in Buckinghamshire, died at Wycombe Hospital on 1 April from a stroke. Senior coroner Crispin Butler heard three staff from Carewatch Mid Bucks had failed to spot tablets handed over by the pharmacy were for a male patient. Mr Butler said action should be taken to prevent similar deaths. A hearing in Beaconsfield on Thursday, where he issued a Prevention of Future Deaths report, followed an inquest in November. In the report he said he was told at the inquest that the carers from Carewatch Mid Bucks gave widow Mrs Planner the wrong medication four times a day for two and a half days. She suffered a fatal stroke because she did not receive her proper apixaban anticoagulation medication. Mr Butler said he would send his concerns to the chief coroner and the Care Quality Commission. He said there was no procedure in place to ensure individual carers read and specifically acknowledged any medication changes. Read full story Source: BBC News, 27 February 2020
  6. 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
  7. 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 applicable beyond the organisation in which this took place and provide a point of wider system learning. Implementing actions and sharing learning While these reports provide a wealth of information, the key challenge is ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning while we recognise the important role these reports have to play, we have some concerns about how they are currently acted on. Implementing actions When actions are requested by the coroner, it is not clear under the current system whether there is a structured process, either at a national or individual organisation level, for monitoring the actions implemented in response to the PFD report. There is also an open question about who is held accountable if the actions requested are not fully implemented, or if the response taken is ineffective. It is difficult to assess how healthcare providers go about this as there appears to be no specific system of monitoring this at a national level. Sharing learning As noted earlier, often the learnings from PFD reports may be applicable beyond the organisation involved. However, at present there appears to be no clear system of sharing these outcomes more widely. Although these reports are published online, they are not in an easily searchable or shareable format and it is difficult to draw out common themes, actions and responses. Furthermore, it is not clear whether NHS England and NHS Improvement undertake any central trend analysis or review to draw out common themes that may be applicable to all organisations, in the same way that the Healthcare Safety Investigation Branch does when it publishes its investigation reports. What do we want to see? We have recently written to the Chief Coroner, Judge Mark Lucraft QC, to raise these issues. We have also drawn this to the attention of Dr Alan Fletcher, the National Medical Examiner. As the new National Medical Examiner system is currently being rolled out across England and Wales, their role in ‘ensuring proper scrutiny of all non-coronial deaths’ will be complementary to the current PFD system. We feel it is important that coroners and medical examiners take a consistent approach to reporting and sharing learnings as widely as possible. When we receive responses, we will take this up directly with NHS England and NHS Improvement, and other national bodies with responsibility for patient safety, along with our ideas of actions that we feel could help to address the current gaps in the system: Implementing actions 1) Analyse reports – Sustainability and transformation partnerships (STPs)/Integrated Care Systems (ICSs) to carry out annual thematic reviews of all PFD reports, Serious Incident (SI) reports and associated safety action plans. These plans can inform future commissioning, safety action plans and Care Quality Commission oversight. 2) National oversight – put in place a clear system of national oversight. Shared learning 3) Increase transparency – make all PFD reports, SI reports and their associated safety action plans available in the public domain. 4) Improve accessibility – create a central repository for all PFD reports, SI reports and associated safety action plans in one database searchable by actions and themes. 5) Standards – put in place patient safety standards for each STP and ICS, with requirements on individual trusts, primary care networks and service providers to share learning from these reports. 6) Publish an annual report – on PFD reports and SI reports including themes for learning and action.
  8. News Article
    Lives may be at risk unless the NHS reviews how stand-in doctors are recruited, a coroner has warned. Harry Richford's death after a series of failings at a hospital in Margate, Kent, was ruled "wholly avoidable". An inquest heard he was delivered by an "inexperienced" locum doctor who was new to the hospital. A national review into the recruitment, assessment and supervision of locums should be carried out, Christopher Sutton-Mattocks said in a report. The coroner wrote that particular emphasis should be considered upon the scope of locums' activities before they are left responsible for out-of-hours labour care. He issued 19 recommendations to prevent future deaths, including a request that NHS England and the Royal College of Obstetricians and Gynaecologists consider such a review, warning "there may be a risk to other lives both at this trust and at other trusts in the future". Read full story Source: BBC News, 19 February 2020
  9. News Article
    A double amputee suffered fatal pressure sores caused by "gross and obvious failings" in her hospital treatment. Janet Prince, from Nottingham, developed the sores after being admitted to Queen's Medical Centre (QMC) in July 2017. The 80-year-old died in January 2019. Assistant Coroner Gordon Clow issued a prevention of future deaths report to Nottingham University Hospitals NHS Trust (NUH). Nottingham Coroner's Court had heard Ms Prince was taken to QMC in Nottingham with internal bleeding on 15 July 2017. The patient was left on a trolley in the emergency department for nine hours and even though she and daughter Emma Thirlwall said she needed to be given a specialist mattress, she was not given one. "No specific measures of any kind were implemented during that period of more than nine hours to reduce the risk of pressure damage, even though it should have been easily apparent to those treating her that [she] needed such measures to be in place," Mr Clow said. Ms Prince was later transferred to different wards, but a specialist mattress was only provided for her a few days before she was discharged on 9 August, by which time Mr Clow said her wounds "had progressed to the most serious form of pressure ulcer (stage four) including a wound with exposed bone". Mr Clow said there were "serious failings" over finding an appropriate mattress and other aspects of her care while at the QMC, including "a gross failure" to prevent Ms Prince's open wounds coming into contact with faeces. Mr Clow said the immediate cause of her death was "severe pressure ulcers", with bronchopneumonia a contributory factor. Recording a death by "natural causes, contributed to by neglect", he said he was "troubled by the lack of evidence" of any changes to wound management at NUH. NUH medical director Keith Girling apologised for the failings in Ms Prince's care, claiming the trust had "learnt a number of significant lessons from this very tragic case". Read full story Source: BBC News, 14 February 2020
  10. News Article
    A coroner has today slammed a hospital for a series of serious failings after a mother bled to death when a medic refused to allow her vital clotting products. Gabriela Pintilie, 36, from Grays, Essex, gave birth to her healthy baby girl, Stefania, in February last year following a C-section after a long labour. But she suffered a major haemorrhage and died from a cardiac arrest hours later. Basildon University Hospital, in Essex, came under fire after it emerged a locum haematologist refused to give Mrs Pintilie the blood after he followed the wrong set of guidelines. The fresh frozen plasma, which could have saved her life, remained outside the theatre after senior staff were not told it was available. Essex Coroner Caroline Beasley-Murray today slammed the hospital for a lack of clear leadership and teamwork during the crucial minutes and hours when Mrs Pintilie suffered a massive haemorrhage. The court heard how the on-call haematologist Dr Asad Omran, who was at home, was called but refused to give permission for vital blood-clotting drugs to be issued until further tests were run. An expert witness said she believed the use of clotting drugs in the 'extreme situation' would have 'significantly increased' the chances of a different outcome. Dr Omran did not initially issue blood-clotting drugs because he followed the wrong protocol. He was following protocol for a normal adult, instead of a woman in labour, which was 'completely at odds with clinical guidelines'. Read full story Source: Mail Online, 20 January 2020
  11. 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 sharing? Thanks - Claire
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