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Found 1,438 results
  1. News Article
    A hospital trust has admitted that a young autistic boy should still be alive had they delivered the appropriate level of care. In an exclusive interview with ITV News, the day before the inquest into his death, Mattheus Vieira's heartbroken parents described him as "special", adding: "And special in a good way, not just special needs." "People may think because he was autistic he was difficult, but it's not the case, he was very easy. "He was the boss of the house, we just miss his presence." Mattheus, aged 11, was taken to King's Lynn Hospital, in Norfolk, with a kidney infection. He struggled to cope with medical staff taking observations, and his notes recorded him as "uncooperative". His dad, Vitor Vieira, told ITV News: "He doesn't like to be touched, even a plaster he doesn't like. "And they say 'Oh he does not co-operate'. He was an autistic boy, what do you expect? Mr Vieira believes staff did not understand his son's behaviour. Mattheus was non verbal and so unable to articulate his distress. Observations were dismissed as "inaccurate" by some medical staff. In fact, they were accurate and indicated that his kidney infection had developed into septic shock. He suffered a cardiac arrest and died, aged 11. Read full story Source: ITV News, 26 February 2024
  2. Content Article
    Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. Wang et al. sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events. They found that patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF.
  3. News Article
    The NHS paid out tens of millions of pounds over maternity failings at a hospital trust which is the subject of a major inquiry. Including legal fees, £101m was paid in claims against Nottingham University Hospitals (NUH) between 2006 and 2023. NUH is facing the UK's largest-ever maternity review, with hundreds of baby deaths and injuries being examined. Experts say lives could be saved if the trust invested more in learning from its mistakes. The NHS paid the money in relation to 134 cases over failings at the Queen's Medical Centre (QMC) and City Hospital. The majority - £85m - was damages for families who were successful in proving their baby's death or injury was a result of medical negligence. Read full story Source: BBC News, 28 February 2024
  4. News Article
    Deaths of newborn babies should be more thoroughly investigated by health boards in Scotland, experts have said after reviewing an increase in infant mortality. The team found inquiries into baby deaths conducted by health boards were “poor quality, inconsistent and incomplete”. The experts added that information about staffing levels on maternity wards at the time of the deaths was so poor that they could not draw any conclusions. They were also unable to determine if health boards enlisted independent, external advisers when considering if deaths could have been prevented. Helen Mactier, a retired neonatologist and chairwoman of the Neonatal Mortality Review, said: “This review has helped to get a clearer understanding of the increase in neonatal deaths that occurred in 2021-22. “We understand that there are still unanswered questions, and our recommendations are focused on ensuring that future opportunities to learn are not missed and acted on in a timely and comprehensive manner.” Read full story (paywalled) Source: The Times, 27 February 2024
  5. Content Article
    Nicholas Gerasimidis had a history of mental illness manifesting as obsessive compulsive disorder (OCD) and anxiety. In 2022, his condition deteriorated. His GP referred him twice to the Community Mental Health Team but the referrals were rejected with medication being prescribed instead, together with advice to contact Talking Therapies.   He was taken on to CMHT workload after being assessed by the Psychiatric Liaison Team in Royal Cornwall Hospital in November 2022. The preferred course of treatment was psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention. There was a waiting list of a year. In May 2023, Mr Gerasimidis became worse. It was felt an informal admission to hospital was required but a bed was not available. He was found hanged at his home address on 3 June 2023.
  6. News Article
    Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition. HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable. Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements. Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations. Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”. He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.” Read full story (paywalled) Source: HSJ, 27 February 2024
  7. News Article
    A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned. Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said. The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients. The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system. The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity. Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”. “It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.” Read full story (paywalled) Source: HSJ, 23 February 2024
  8. Content Article
    On 18 December 2022, Emily Harkleroad collapsed when out with a friend. She was taken by ambulance to the University Hospital of North Durham Emergency Department. Despite staff recognising that pulmonary embolism was the likely diagnosis, there were failures to provide Emily with appropriate and timely treatment for pulmonary embolism. Errors and delays in the Emily’s medical treatment resulted in her not receiving the anticoagulant treatment that she needed, and which would, on a balance of probabilities, have prevented her death. She died as a result of pulmonary embolism in the early hours of 19 December 2022 at the University Hospital of North Durham.
  9. News Article
    Bereaved parents who lose a baby before 24 weeks of pregnancy in England can now receive a certificate in recognition of their loss. Ministers say they have listened to bereaved parents who have gone through the painful experience of miscarriage. Campaigners said they were "thrilled" that millions of families would finally get the formal acknowledgement that their baby existed. All parents who have experienced baby loss since September 2018 can apply. They should visit the gov.uk website - applicants must be at least 16 years old, have been living in England at the time of the loss and be one of the baby's parents or surrogate. In Wales, there are plans to deliver a similar scheme. Babies who are born dead after 24 completed weeks of pregnancy are called stillbirths, and their deaths are officially registered. But this does not happen for babies who die before that stage. Pregnancy loss or miscarriage before 24 weeks is the most common complication of pregnancy, experienced by an estimated one in five women in the UK. Read full story Source: BBC News, 21 February 2024
  10. Content Article
    On 29 December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26 January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient.   Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act.   This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure. She was seen by the Home-Based Treatment Team (HBTT) on 28 January and 2 February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9 February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home- Based Treatment Team on 11th February. She was seen by that team on 11, 12, and 13 February. There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14 February 2023 she took a fatal overdose of prescribed zopiclone at her home address.
  11. News Article
    Italy will carry out an inquiry into its handling of the coronavirus pandemic in a move hailed as “a great victory” by the relatives of people killed by the virus but criticised by those who were in power at the time. Italy was the first western country to report an outbreak and has the second highest Covid-related death toll to date in Europe, at more than 196,000. Only the UK’s death toll is higher. The creation of a commission to examine “the government’s actions and the measures adopted by it to prevent and address the Covid-19 epidemiological emergency” was approved by the lower house of parliament after passing in the senate. Consuelo Locati, a lawyer representing hundreds of families who brought legal proceedings against former leaders, said: “The families were the first to ask for a commission and so for us this is a great victory. The commission is important because it has the task, at least on paper, to analyse what went wrong and the errors committed so as not to repeat the massacre we all suffered.” Read full story Source: The Guardian, 15 February 2024
  12. News Article
    "Cultural and ethnic bias" delayed diagnosing and treating a pregnant black woman before her death in hospital, an investigation found. The probe was launched when the 31-year-old Liverpool Women's Hospital patient died on 16 March, 2023. Investigators from the national body the Maternity and Newborn Safety Investigations (MSNI) were called in after the woman died. A report prepared for the hospital's board said that the MSNI had concluded that "ethnicity and health inequalities impacted on the care provided to the patient, suggesting that an unconscious cultural bias delayed the timing of diagnosis and response to her clinical deterioration". "This was evident in discussions with staff involved in the direct care of the patient". The hospital's response to the report also said: "The approach presented by some staff, and information gathered from staff interviews, gives the impression that cultural bias and stereotyping may sometimes go unchallenged and be perceived as culturally acceptable within the Trust." Liverpool Riverside Labour MP Kim Johnson said it was "deeply troubling" that "the colour of a mother's skin still has a significant impact on her own and her baby's health outcomes". Read full story Source: BBC News, 16 February 2024
  13. Content Article
    In December 2022, a newly formed group called 'Long Covid Doctors for Action' (LCD4A) conducted a survey to establish the impact of Long Covid on doctors. When the British Medical Association published the results of the survey, the findings were both astonishing and saddening in equal measure.[1] The LCD4A have now decided that enough is enough and that it is now time to stand up and take positive action. They have initiated a group litigation against those who failed to exercise the ‘duty of care’ that they owed to healthcare workers across the UK during the pandemic.  In this blog, I summarise how and why I feel our healthcare workers have been let down by our government and why, if you are one of these healthcare workers whose life has been effected by Long Covid, I urge you to join the group litigation initiative.
  14. News Article
    The family of a man who needlessly died after a 12-hour delay in surgery have called for changes at a troubled NHS trust as regulators expressed alarm about patient safety and waiting times. The Care Quality Commission (CQC) upgraded the surgery department at the Royal Sussex county hospital in Brighton from “inadequate” to “requires improvement” at a time when it is at the centre of a police investigation into dozens of patient deaths, allegations of negligence and cover-up. In their report, the regulator expressed concern about already long and lengthening waiting times, repeated cancelled operations and staff shortages that could compromise safety. The inspection report comes as the Guardian can reveal the trust apologised and settled with the family of Ralph Sims, who died aged 65 after heart surgery in April 2019 when doctors failed to act appropriately to a drop in his blood pressure. Sims, who was a keen runner, suffered a drop in blood pressure and developed an irregular heart rhythm eight hours after surgery to replace an aortic valve at the hospital. An internal investigation into Sims’ treatment acknowledged that hospital staff failed to “recognise the significance of the fall in blood pressure”. University Hospitals Sussex NHS foundation trust, which runs the hospital, accepted that the father of three should have returned to surgery to identify the cause of his deterioration. Instead, medics decided that he should be observed overnight. Due to another emergency case, an angiogram was not carried out on Sims until just before noon the following day – 12 hours after the drop in pressure. The delay caused irreversible – and avoidable – heart muscle damage, leading to his death five weeks later. The family said: It added: “Whilst the trust has apologised to our family it feels hollow. Ralph’s death was entirely unnecessary, and despite the issues in his care, it took the trust several years to apologise.” Read full story Source: The Guardian, 14 February 2024
  15. News Article
    A man with Down’s Syndrome and dementia died in hospital after not being fed for nine days. The 56-year-old was admitted to Poole hospital with a hip fracture after falling over at a Bournemouth care home, where he had been receiving care. On admittance, he was taken to the trauma and orthopaedics ward, where he was listed as ‘nil by mouth’, as he had trouble swallowing. Nine days later, he died of pneumonia after a ‘series of errors’ at the hospital. Now, the man’s father has been given £22,500 in compensation, after an incident investigation at the hospital. Allegations made against the hospital included a failure to feed the patient for nine days, causing "his subsequent severe deterioration and death". The hospital failed to adequately monitor and investigate his condition, while failing to provide senior doctors, it was alleged. This left unsupervised junior doctors who did not have access to senior staff or any way to escalate their concerns, allegations said. This, it was claimed, was not done when the patient was still nil by mouth after nine days, despite the fact he was suffering from pneumonia. Read full story Source: Yahoo News, 9 February 2024
  16. Content Article
    In November 2023, the Parliament’s Justice Select Committee launched a follow-up inquiry to The Coroner Service, to examine changes and progress since the first inquiry in 2020-2021.
  17. News Article
    Lawyers and charities tell of mothers told to ‘labour at home as long as they can’, dangerously few midwives and ‘lies’ during natal care. As Rozelle Bosch approached her due date she had every reason to expect a healthy baby. Neither she, her husband nor the midwives knew that the child was in the breech position at 30 weeks. When her waters broke a fortnight early, Bosch and her husband, Eckhardt, both first-time parents, had been reassured by NHS Lanarkshire that all was well and that the mother was “low risk”. They were sent home from Wishaw hospital and told to monitor conditions until the pregnancy became “active”. Shortly before 11pm on 1 July 2021, her husband called an ambulance saying that Bosch was in labour and was giving birth. Bosch was in an upstairs bedroom on her knees and paramedics noted that “the baby was pink”. They soon asked the control room for a doctor or midwife to attend but none were available. By the time the ambulance took the family to hospital, the baby had turned blue. Within two days, baby Mirabelle had died. She had become trapped with only her feet and calves delivered while the couple were still at home. A post-mortem has found that Mirabelle suffered oxygen deprivation to the brain from “head entrapment” during delivery. Last month, her father explained to a fatal accident inquiry (FAI) at Glasgow sheriff court: “We were told Rozelle was healthy and Mirabelle was healthy. I think this was a lie and the consequences have me standing here today.” The way that the tragedy unfolded is striking, not just because of the devastating consequences, but because it is not an entirely isolated case. The same FAI is examining the deaths of two other newborns, Ellie McCormick and Leo Lamont, who also died in NHS Lanarkshire less than a month apart in 2019. Experts say it is rare for the Crown and Procurator Fiscal Service to group investigations in this way. Darren Deery, the McCormicks’ lawyer and a medical negligence specialist with Drummond Miller, said he had noticed a “considerable increase” in parents contacting the law firm in the past three years. Read full story (paywalled) Source: The Times, 11 February 2024
  18. News Article
    An investigation has been launched after a woman died days after being found unconscious underneath her coat while waiting in A&E for seven hours. The 39-year-old woman is understood to have first attended A&E at Queen’s Medical Centre in Nottingham on the evening of 19 January complaining of a severe headache. She was triaged and then observed by nurses three times. Her case was escalated but she was not seen by a doctor before being discovered. When the woman was called to see a doctor, she did not respond. It was assumed that she had left A&E because she had waited so long. She was discovered and transferred to intensive care but died three days later on 22 January. A source familiar with the hospital told LBC, which first reported the incident, that the A&E department could have up to 80 patients waiting at a single time and that wait times could be as long as 14 hours. Dr Keith Girling, the medical director at Nottingham university hospitals NHS trust, said: “I offer my sincere condolences to the family at this difficult time. An investigation, which will involve the family, will now take place and until this has been concluded, we are unable to comment further.” Read full story Source: The Guardian, 10 February 2024
  19. News Article
    The NHS is failing some parents whose children die unexpectedly, a leading paediatrician has told BBC Panorama. About 50 children's deaths in the UK every year are termed as "sudden unexplained death in childhood" (SUDC). Little is known about what causes them. Gavin and Jodie's two-year-old son Addy died unexpectedly in November 2022. BBC Panorama followed the parents over nine months as they searched for answers to why their son died - and whether it could have been prevented. Even after a forensic post-mortem examination, no-one could work out why the little boy went to sleep and never woke up, so his death was categorised as SUDC. When a child dies unexpectedly, a review is held to gather information about what happened. The NHS is required to assign a key worker to help bereaved parents to navigate this process, and provide emotional support. The role of key worker can be taken by a range of practitioners and is often a specialist nurse. However, even though it is a mandatory requirement, a survey carried out by the Association of Child Death Review Professionals (ACDP) found that more than half of NHS areas in England do not have a specialist nurse to visit parents after an unexpected death. "It makes me really angry," says paediatrician Dr Joanna Garstang, the chair of the ACDP, who runs one of the few teams in England that support parents. "Bereaved families after the sudden death of a child are the most vulnerable people. And if we don't put in early support… we're setting these parents up for a lifetime of misery." Read full story Source: BBC News, 5 February 2024
  20. Content Article
    During the first wave of Covid-19, the drug hydroxychloroquine was used off-label despite the absence of evidence documenting its clinical benefits. Since then, a meta-analysis of randomised trials showed that the drug's use was associated with an 11% increase in the mortality rate. This study in the journal Biomedicine & Pharmacotherapy aimed to estimate the number of hydroxychloroquine-related deaths worldwide.
  21. News Article
    Jason Watkins, a British actor, has urged A&E units to look again at procedures surrounding infants as he has channels his anger at his young daughter’s death from sepsis into trying to “improve the system”. The actor said that his fury at the death of Maude aged two on New Year’s Day 2011 led him to smash up his shower. “It wasn’t anger at any individual, it was anger at fate. Why should we deserve this?” he told Andy Coulson’s Crisis What Crisis? podcast. “You feel really vulnerable and there’s a sort of rage against that. And there are all these different ways of resolving and wrestling out of this horrible dark pit that you’re in." He now campaigns for the UK Sepsis Trust. “I was never angry at any individual,” he said. “My anger was fuelled into trying to work out better ways of dealing with sepsis, or even more than that, the way that we look at infants in A&E. Because you know, it’s a funding issue, it’s an organisational issue. It’s another conversation. “Because I had identified that there wasn’t an individual at fault in the hospital, it has to be the system. So we’ve got to improve it. My anger is fuelled into that. There’s no bitterness. Nobody made a technical mistake, it’s just nobody really thought of the possibilities of what could be happening. “For me the whole of looking at infants arriving at A&E needs to be looked at again. Because if I say that Maude died twelve years ago, and that the ombudsman report about sepsis a couple of months ago said that nothing had changed about sepsis, now, that was like a body-blow, that makes me feel sick even thinking about it now, because we’ve worked so hard over that time.” Read full story Source: The Times, 1 February 2024
  22. News Article
    Deaths from cancer in the UK are set to rise by more than 50% in the next 26 years, stark new estimates suggest. Experts from the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO) have found there were 454,954 new cases of cancer in the UK in 2022 and warned this is expected to rise to 624,582 by 2050. In 2022, 181,807 people died in Britain from cancer, but researchers warned this is expected to rise to 279,004 by 2050 – a 53% increase. The estimates suggest the rising rates of cancer will be driven by the UK’s growing and ageing population. However, researchers have also called for new policies to tackle levels of smoking, unhealthy diets, obesity and alcohol to help lower the expected surge in cases. The study examined cancer data from 115 different countries and estimated global cases would rise by 77 per cent, from 20 million in 2022 to 35 million in 2050. The organisations estimate that cancer deaths around the world will almost double from 9.7 million to 18.5 million in that time. Dr Panagiota Mitrou, director of research, policy and innovation at the World Cancer Research Fund, said the new estimates “show the increased burden that cancer will have in the years to come”. “UK governments’ failure to prioritise prevention and address key cancer risk factors like smoking, unhealthy diets, obesity, alcohol and physical inactivity has in part widened health inequalities,” she added. Read full story Source: The Independent, 1 February 2024
  23. News Article
    A prostate cancer patient went a year without a check-up because his referral to a consultant was lost. An inquest into the death of Thomas Ithell also heard that when the error was spotted it was not recorded because staff at Wrexham Maelor Hospital were too busy. The 77-year-old from Wrexham died in November 2022 after being admitted to hospital with shortness of breath. Assistant Coroner for North Wales East and Central, Kate Robertson, has submitted a Prevention of Future Deaths report to the health board in relation to Mr Ithell's case. As well as concerns over the lack of an investigation, she also questioned how the patient's follow-up appointment was missed. "There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring," she wrote, referring to a type of blood test that helps diagnose prostate cancer. She was also concerned to learn that the hospital's Datix system - used for reporting incidents such as Mr Ithell's - had been described as "not user-friendly". Time constraints also sometimes prevented staff from completing these reports, thereby failing to trigger subsequent investigations by the board, the assistant coroner added. "I remain incredibly concerned that where matters are not raised in accordance with internal health board processes that assurances given to me in previous Prevention of Future Deaths reports cannot be supported," Ms Robertson added. Read full story Source: BBC News, 27 January 2024
  24. Content Article
    Panorama investigates the crisis in maternity care that is putting women and babies at risk. Whistleblowers at a trust in Gloucestershire tell reporter Michael Buchanan about the deaths of mothers and babies, the dangers of understaffing and a culture that they say has failed to learn from mistakes. The regulator, the Care Quality Commission, has said that maternity services at the trust are inadequate, and Panorama has calculated that maternal deaths there are almost double the national average. The trust says that it's deeply sorry for failings in its care and that it's made improvements to its maternity services.
  25. Content Article
    Thomas Ithell was aged 77 at the time of his death on 20 November 2022. He was diagnosed with prostate cancer in September 2017 and biopsies revealed bilateral adenocarcinoma of the prostate. He underwent radiotherapy in 2018 and hormone deprivation treatment. From April 2021 onwards his PSA levels increased periodically. In October 2021 his level was 5.5ng/ml having been 1.5ng/m lin April 2021 and 2.7ng/m in July 2021 indicating a recurrence of the cancer and likely incurable. Thomas Ithell was reluctant to undergo further hormone treatment as he found tolerating the side effects difficult. He did not then have his PSA levels tested after November 2021 and was not reviewed at all due to becoming missed to follow up. After he had been seen by the nurse practitioner on 5 November 2021, the letter written by the nurse practitioner for advice from the consultant did not reach the consultant. He was reviewed by a consultant on 22 October 2022 after an urgent suspected cancer GP referral following routine set of blood tests in September 2022, some 10 months later. Mr Ithell died in hospital on 20 November 2022 having been admitted with shortness of breath, the malignancy having caused his death.
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