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Found 500 results
  1. News Article
    When Tassie Weaver went into labour at full term, she thought she was hours away from holding her first child. But by the time she was giving birth, she knew her son had died. Doctors had previously told Tassie to call her local maternity unit immediately, she says, as she was considered high risk and needed monitoring, due to high blood pressure and concerns about the baby's growth. But a midwife told her to stay at home. Three hours later she called again, worried because now she couldn't feel her baby moving. Again, she was told to stay at home, the same midwife saying that this was normal because women can be too distracted by their contractions to feel anything else. "I was treated as just a kind of hysterical woman in pain who doesn't know what's going on because it's their first pregnancy," the 39-year-old tells us. When she called a third time, a different midwife told her to come to hospital, but when she arrived it was too late. His heart had stopped beating. Tassie and her husband John believe Baxter's stillbirth at the Leeds General Infirmary (LGI), four years ago, could have been prevented - and a review by the trust identified care issues "likely to have made a difference to the outcome". The couple are among 47 new families who have contacted the BBC with concerns about inadequate maternity care at Leeds Teaching Hospitals (LTH) NHS Trust between 2017 and 2024. As well as the new families, three new whistleblowers - two who still work for the trust - have shared concerns about the standard of care at its two maternity units - at the LGI and St James' University Hospital. This is in addition to the two we spoke to in the initial BBC investigation. Read full story Source: BBC News, 17 June 2025
  2. News Article
    A hospital trust and a staff member have been found guilty of health and safety failings over the death of a young woman in a mental health unit. Alice Figueiredo, 22, was being treated at Goodmayes Hospital, east London, when she took her own life in July 2015, having previously made many similar attempts. Following a seven-month trial at the Old Bailey, a jury found that not enough was done by the North East London Foundation NHS Trust (NELFT) or ward manager Benjamin Aninakwa to prevent Alice from killing herself. The trust was cleared of the more serious charge of corporate manslaughter, while Aninakwa, 53, of Grays in Essex, was cleared of gross negligence manslaughter. The jury deliberated for 24 days to reach all the verdicts, setting a joint record in the history of British justice, according to the Crown Prosecution Service (CPS). Both the trust and Aninakwa were convicted under the Health and Safety at Work Act. It was only the second time an NHS trust has faced a corporate manslaughter charge. During the trial, prosecutors said that not only was Alice repeatedly able to self-harm while she was in hospital, but that these incidents were not properly recorded or assessed. The court also heard there were concerns about Benjamin Aninakwa's communication, efficiency, clinical and leadership skills. The trust had previously placed him on a performance improvement plan for three years, which ended in December 2014. In addition, there was a high turnover of agency staff on the ward, the court heard. Mrs Figueiredo says she raised concerns about her daughter's care verbally and in writing on a number of occasions to the hospital and to Mr Aninakwa. After Alice died, she said the family found it very difficult to get answers about what happened. For nearly a decade they gathered evidence and pressed both the police and the CPS to take action. Read full story Source: BBC News, 9 June 2025
  3. Content Article
    In high-income countries, critical illness in children is rare, and often difficult for physicians to distinguish from common minor illness until late in the disease. Parents or caregivers are well positioned to detect early and subtle signs of deterioration, but the relationship between their concerns and patient outcomes is unknown. This study examined the relationship between documented caregiver concern about clinical deterioration and critical illness in children presenting to hospital. It found that caregiver concern for clinical deterioration is associated with critical illness in paediatric patients and, after adjusting for variables including abnormal vital signs, had a strong association with ICU admission and mechanical ventilation. Rapid response systems should incorporate proactive assessment of parent or caregiver concerns for deterioration.
  4. Content Article
    More information about "Top 10 priorities for patient safety in surgery (Royal College of Surgeons of Edinburgh)"
    We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors
  5. News Article
    A man said he was left "begging for help" from doctors after he suffered life-changing injuries due to sepsis caused by failures at his local hospitals. Paul Robinson, 70, developed recurring sepsis for almost a year after being hospitalised on multiple occasions in Brighton and Worthing. The company director from Goring, in West Sussex, said: "I've lost my freedom, confidence, business, very nearly my family home, and almost my will to live." Mr Robinson was diagnosed with cancer in 2018. He successfully had a lump removed from his lung. But during chemotherapy, he became unwell and was diagnosed with sepsis. He said he went through several relapses with sepsis and was in hospital for 13 days. "I was left for 11 months with recurring, untreated sepsis – despite begging for help," he said. Describing his care at Worthing Hospital and Royal Sussex County Hospital in Brighton, he said there was a breakdown in communication between nurses, doctors and departments. He said there had been "systemic failures" and "ignored warnings" with his care. "We asked for help 47 times, and we were ignored 47 times," he added. "Every day I see NHS campaigns about spotting the signs of sepsis. We knew the signs, we pleaded for help, and nobody listened." Read full story Source: BBC News, 5 June 2025
  6. News Article
    A hospital boss has apologised "unreservedly" after the death of a 12-year-old girl which led a coroner to raise concerns about the "discrimination of disabled children". Rose Harfleet died at Royal Surrey County Hospital, in Guildford, on 30 January 2024, having attended its emergency department the day before with abdominal pain and vomiting. Assistant coroner for Surrey, Karen Henderson, said in a recent report that there was a failure of the medical and nursing staff to appreciate Rose was clinically deteriorating. The coroner said Rose, who from birth was diagnosed with mosaic trisomy 17 with global developmental delay, was "wholly reliant on her mother to advocate on her behalf". But she said at the hospital no history was taken from Rose's mother and that the severity of her signs and symptoms were underestimated. She said poor clinical decisions contributed to Rose's death. "This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children," she added. Read full story Source: BBC News, 4 June 2025
  7. News Article
    Doctors trust a parent’s gut instinct that their child is becoming severely ill, research has shown, finding that it is a better indicator of health than medical tests. The study analysed data from almost 190,000 A&E visits by children in Melbourne, Australia, where the parents were routinely asked: “Are you worried your child is getting worse?” Parents’ intuition was “significantly” linked to the likelihood of admission to an intensive care unit (ICU), with children four times more likely to need ICU care if their parents had voiced concerns. Read full article (Paywalled) Source: The Times, 29 May 2025
  8. News Article
    Wes Streeting has apologised to families harmed by poor maternity care for taking six months to get back to them, and claimed he is pressing NHS England for a “more comprehensive and stronger set of actions” to improve safety. The health and social care secretary had previously met with a group of campaigners for improved standards in December. But in a letter to them this week he admitted: “It has taken far longer than anticipated to come back to you with concrete plans for the actions we will take….I also realise that the lack of any update may have inadvertently implied that it was not a priority for me. This had never been my intention.” The letter, seen by HSJ, added: ”I was keen that they were sufficiently ambitious to reflect the scale of the challenge with maternity and neonatal care… I have asked NHS England to continue working up a more comprehensive and stronger set of actions that will deliver the change we need – and subject to your views would like to ask them to work directly with yourselves.” The delay in contact since December has caused some disquiet among families affected by recent maternity scandals, who felt they had been promised swifter action. Some groups favour a public inquiry into maternity nationally – which Mr Streeting is thought unlikely to offer – while other families hope for a “maternity czar” to drive forward change. In his letter this week, the MP said “on behalf of the Department, I offer my sincere apologies” for the delay in his response and action, and asked to meet the families again to discuss his plans, which include a set of immediate actions as well as longer-term plans to tackle entrenched issues. Read full story (paywalled) Source: HSJ, 28 May 2025
  9. Content Article
    This episode of ByteMed explores the critical role of patient and caregiver voices in shaping healthcare, with Chris Johnston and Alies Maybee from the Patient Advisors Network (PAN)—a Canadian not-for-profit dedicated to empowering patients and caregivers to drive meaningful healthcare improvements. They discuss how PAN fosters a community of practice, connecting and supporting patient and caregiver partners at all experience levels. Learn how their expertise helps healthcare organizations make better decisions and why active patient involvement is essential for creating a more effective, patient-centred system.
  10. Content Article
    The overarching vision of the NIHR Yorkshire and Humber Patient Safety Research Collaboration (PSRC) is to co-produce innovative solutions to make care safer for patients and their families. Key to this is ensuring that these solutions reflect and meet the needs of our diverse communities. This can be achieved by working with and for patients, families, and health and social care staff, grounding our research in their daily realities and the evolving system within which care is delivered. This PPIE strategy offers the mechanisms by which we can deliver on this, recognising that respectful and trusting relationships are the cornerstones to making effective change.
  11. Content Article
    The last two or three years have seen an unprecedented number of developments in the UK (England in particular) which can be loosely described as being advances or planned advances in patient and family empowerment (or “engagement” in patient safety). This editorial from Peter Walsh explores the potential and challenges of Martha's Rule, Hillsborough Law, Patient Safety Partners, the Harmed Patient Pathway and the Independent Advice and Advocacy.
  12. Event
    This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. Knowing things may have gone wrong can feel a heavy burden and a complex emotional situation to be managing. Often, we avoid visiting difficult emotions in others, as well as ourselves, because we don’t feel confident or skilled, or we feel fearful of not doing it perfectly. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email [email protected] for discount code.
  13. News Article
    A senior doctor has been accused of wrongly failing to escalate the care of a 13-year-old girl whose death led to the adoption of Martha’s rule, which gives the right to a second medical opinion in hospitals. At a disciplinary tribunal in Manchester, Prof Richard Thompson was also said to have provided a colleague with “false and misleading information” about the condition of Martha Mills. Martha died on 31 August 2021 at King’s College hospital (KCH) in south London after contracting sepsis. In 2022, a coroner ruled that she would most likely have survived if doctors had identified the warning signs of her rapidly deteriorating condition and transferred her to intensive care earlier, which her parents had asked doctors to do. Thompson, a specialist in paediatric liver disease, and the on-duty consultant – although he was on call at home – on 29 August 2021, is accused by the General Medical Council (GMC) of misconduct that impairs his fitness to practise. Opening the GMC’s case at the Medical Practitioners Tribunal Service on Monday, Christopher Rose said, based on a review of the case by Dr Stephen Playfor, a medical examiner at Manchester Royal Infirmary, Thompson: Should have taken more “aggressive intervention” between noon and 1pm on 29 August, including referring Martha to the paediatric intensive care unit (PICU). Should have gone into the hospital from about 5pm to carry out an in-person assessment of a rash Martha had developed. Gave “false, outdated and misleading information” in a phone call at approximately 9.40pm to Dr Akash Deep in the PICU team. Read full story Source: The Guardian, 19 May 2025
  14. Content Article
    The Saudi Patient Safety Center works to reach the largest possible number of patients and their families while receiving healthcare by visiting them at the healthcare facility and talking to them and communicating the message of health empowerment and providing information that helps them to be an active patient in health care through the Patient Safety Caravan which is a virtual Caravan that includes group of people visiting patients and their families in hospitals (in inpatient wards, outpatient clinics, emergency departments , etc.) to increase patient safety awareness through empowering, educating, and supporting them. Objectives: To reach as many patients and families as possible to improve the safety of their healthcare encounters. To increase patient's safety level in the healthcare facilities and to ensure patients and families' participations in their treatment plan with healthcare providers. To raise volunteers' awareness about patient safety to share with patients and families. Collaborating with patients experience centers at hospitals to activate patient's empowerment concept through their daily duties.
  15. Content Article
    WHO champions patient-centred health care, where patients and their families shape health care decisions. Watch this video to learn about how engaging patients may help to ensure patient safety.
  16. Content Article
    An estimated one in every 10 patients experience harm in health care facilities, and each year, there are more than three million deaths globally due to unsafe health care. Most of the patient harm is preventable, with patient and family engagement being one of the most important strategies for reducing harm. This video shows how listening to the voices of patients, families and caregivers can lead to safer health care for all.
  17. Content Article
    Expectations of patient and family involvement in investigations of healthcare harm are becoming conventional. Nonetheless, how people should be involved, is less clear. Therefore, the “Learn Together” guidance was co-designed, aiming to provide practical and emotional support to investigators, patients and families. This study evaluated the use of the Learn Together guidance in practice—designed to support patient and family involvement in investigations of healthcare harm. Findings The guidance supported the systematic involvement of patients and families in investigations of healthcare harm and informed them how, why, and when to be involved across settings. However, within hospital Trusts, investigators often had to conduct “pre-investigations” to source appropriate details of people to contact, juggle ethical dilemmas of involving vs. re-traumatising, and work within contexts of unclear organisational processes and responsibilities. These issues were largely circumvented when investigations were conducted by an independent body, due to better established processes, infrastructure and resources, however independence did introduce challenge to the rebuilding of relationships between families and the hospital Trust. Across settings, the involvement of patients and families fluctuated over time and sharing a draft investigation report marked an important part of the process—perhaps symbolic of organizational ethos surrounding involvement. This was made particularly difficult within hospital Trusts, as investigators often had to navigate systemic barriers alone. Organisational learning was also a challenge across settings. Conclusions Investigations of healthcare harm are complex, relational processes that have the potential to either repair, or compound harm. The Learn Together guidance helped to support patient and family involvement and the evaluation led to further revisions, to better inform and support patients, families and investigators in ways that meet their needs (https://learn-together.org.uk). In particular, the five-stage process is designed to centre the needs of patients and families to be heard, and their experiences dignified, before moving to address organisational needs for learning and improvement. However, as a healthcare system, we call for more formal recognition, support and training for the complex challenges investigators face—beyond clinical skills, as well as the appropriate and flexible infrastructure to enable a receptive organisational culture and context for meaningful patient and family involvement. Related reading on the hub: The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations
  18. Content Article
    Martha’s Rule is a key patient safety initiative to ensure patients, families, carers and hospital staff’s concerns about a worsening health condition are listened to. This can help detect deterioration early, so action can be taken to prevent more serious health problems. Effective communication is crucial to the success of Martha’s Rule. NHS England has launched a Martha’s Rule communications toolkit providing trusts with a range of resources to support them to: raise awareness of Martha’s Rule among hospital staff, patients, families, and carers support staff to understand their role in implementing Martha’s Rule, ensuring they feel confident to escalate concerns and ask for additional support when necessary empower patients and families to voice concerns about deteriorating health and to seek rapid reviews when needed.
  19. Event
    Join WHO for a virtual webinar exploring how engaging patients and families at policy, facility, and community levels can help strengthen safer health care systems. Hear insights from health leaders and patient advocates around the world. Register
  20. Event
    Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.
  21. Event
    Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.
  22. Event
    Facere Melius are the only NHS Framework Provider approved training supplier that worked closely with NHS England in developing tools and guidance to support PSIRF. Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations Being open and apologising when things go wrong Challenges/complexities associated with cases where there is more than one investigation Effective communication, including dealing with conflict and difficult conversations Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation Sharing findings Signposting and support: including loss, trauma and stress Who should attend Lead investigators conducting patient safety incident investigations Executive and service lead for duty of candour Executive and service lead for patient safety Executive and service lead for the supporting response to patient safety incidents Investigators supporting patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.
  23. Event
    This conference brings together leading experts at the forefront of ensuring adherence to Martha’s Rule and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. The conference will also discuss the new approach to managing acute physical deterioration through the prevention, identification, escalation, response – PIER approach which is currently being implemented Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. Register Reduced rate places can be booked online with code HCUK195MRSO
  24. Event
    This conference brings together leading experts at the forefront of ensuring adherence to Martha’s Rule and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. The conference will also discuss the new approach to managing acute physical deterioration through the prevention, identification, escalation, response – PIER approach which is currently being implemented Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. Register Reduced rate places can be booked online with code HCUK195MRSO
  25. News Article
    A mother whose daughter was found to have been neglected by a hospital before taking her own life has blamed the “failures of the system” for her daughter’s death and has demanded improved care for future patients. Court documents show Iona Imogen Lee’s suicide is one of at least five deaths that failures at Derbyshire’s mental health units caused or contributed to in the past decade. The health and social care regulator is currently reviewing information over three deaths at the units. Morag Lee opened up about her “inspiring, friendly, loved” daughter Iona’s heartbreaking final hours on the Hartington Unit at the Chesterfield Royal Hospital in Chesterfield, before the 24-year-old was transferred to the ICU where she died on 18 September 2023. The 57-year-old mother, from Derby, spoke to The Independent after a coroner ruled in January that her child had died by “suicide contributed to by neglect” on the ward where she had been detained under the Mental Health Act on 15 September 2023. It was found at the inquest into Iona’s death in January that “there were a series of errors in the planning, management and implementation of Iona's observations after admission” and that “instruction, information and supervision were all inadequate, as was the primary induction”. The jury concluded that Iona’s observation level should have been raised to being kept within staff’s eyesight, but due to staff shortages on the ward, she was only being checked intermittently. Even then, this should have been at least every 15 minutes, but the 24-year-old was not found until 43 minutes after she was last seen. MS Lee raised “serious concerns” about the management of the Hartington Unit and believes blame also lies with this and previous governments in their role overseeing a crippled NHS. Inquests over the last 10 years identified failures by the Hartington and Radbourne Units that caused or contributed to at least five deaths, including over incorrect decisions around patients being granted leave or discharged from the wards, wrongful prescription of medications, and inadequate risk assessment. In a report, coroner issued a warning to the Trust asking for policy change for fear of risking future deaths. Calling for change for future patients, Ms Lee said: “In the past year, the hospital have changed their policies, but guidance was in place two years ago that wasn’t followed and led to my daughter’s death – so how do we know that what’s in place now will continue being implemented? What reassurances does the public have?” Read full story Source: The Independent, 13 April 2025

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