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Found 1,458 results
  1. News Article
    Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss? The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned. “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter. “So Charlotte spent four years in agony,” says James, “thinking it was her.” Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says. Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”. James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them. “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says. Read full story Source: The Guardian, 26 March 2024
  2. Content Article
    Along with the Care Inspectorate, Healthcare Improvement Scotland have established a National hub for reviewing and learning from the deaths of children and young people (National hub). The National hub uses evidence to deliver change. It ultimately aims to help reduce preventable deaths and harm to children and young people.  
  3. News Article
    A new system requiring GPs to agree death certificates with a medical examiner is unlikely to launch at the beginning of April, it has emerged. The system, which will see medical examiners (MEs) providing independent scrutiny of all deaths in the community which are not taken to the coroner, had previously been due to come in from April last year. However, it was delayed by one year to allow time for Parliament to introduce the necessary supporting legislation and, according to the Department of Health and Social Care (DHSC), this has yet to happen. A spokesperson told Pulse that the Government’s intention is to still introduce secondary legislation ‘from April’ to implement death certification reform. However, it could not confirm the exact date the system will launch and said it would provide an update before the end of March. Nottingham GP Dr Irfan Malik told Pulse that local GPs and practice staff ‘seem to be aware there is a delay’ but have had ‘no official emails’ or communication confirming the delays. Read full story Source: Pulse, 20 March 2024
  4. News Article
    Lessons have not been learned to prevent further deaths in north Wales, coroners have told the health secretary. Over the past year, coroners in Wales wrote 41 "prevention of future deaths reports" and more than half were issued to Betsi Cadwaladr health board. Health Secretary, Eluned Morgan, said 27 reports issued since January 2023 was "of significant concern". Betsi Cadwaladr health board said every report was taken very seriously and work was ongoing to respond to key themes. Ms Morgan said all but three of the deaths happened before the health board was moved back into special measures in February 2023. The "systemic issues" that emerge as common themes from the coroners' reports include: the quality of investigations and effectiveness of actions a lack of integrated electronic health records impacting care the impact of delays in the system on ambulance response times. In a written statement earlier this week, Ms Morgan said the health board had given assurances that it was taking the matter "extremely seriously". Read full story Source: BBC News, 21 March 2024
  5. Content Article
    This report outlines the findings of an independent investigation into the conduct of a spinal consultant, Doctor F, who formerly worked at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust).
  6. News Article
    A campaigner in Norfolk says the "deaths crisis" at the county's mental health trust is getting worse. Bereaved relatives met the mental health minister, Maria Caulfield, to discuss failings at the Norfolk and Suffolk NHS Foundation Trust (NSFT). The trust says it is on a "rapid, and much-needed journey of improvement". Mark Harrison, from the Campaign to Save Mental Health Services in Norfolk and Suffolk, said: "We judge people by what they do, not what they say." Members of the campaign group met Ms Caulfield and other MPs in Westminster on 12 March and demanded an independent public inquiry into the trust. It came after a report last summer which found that more than 8,000 mental health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. At the meeting, it was agreed Ms Caulfield would meet bosses at the NSFT. The health select committee will also be asked to conduct an inquiry into the trust as part of a broader public inquiry. But Mr Harrison said he had little confidence anything would change. "The deaths crisis is just out of control and it's accelerating," he said. "We have been doing this for 10 years. Every time somebody promises to do something, it doesn't come to anything." Read full story Source: BBC News, 20 March 2024
  7. News Article
    An inquest into the death of a baby boy who died two weeks after birth in a Sussex hospital has found there were missed opportunities in the care of his mother. Orlando Davis was born by emergency caesarian section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on 10 September 2021 following a normal and low risk pregnancy. He was born with no heartbeat and his parents were told he had suffered an irreversible brain injury after being starved of oxygen - after his mother Robyn Davis experienced seizures during labour, caused by a rare condition that went "completely unrecognised" by staff. Orlando died in Robyn and husband Jonny’s arms on 24 September 2021 at 14 days old due to his catastrophic brain injury. His mother had to be put in an induced coma, but has since recovered. But his parents say his death was avoidable. Today at the inquest into Orlando's death, senior coroner, Ms Penelope Schofield said a lack of understanding of hyponatremia contributed to neglect of Orlando. Mrs Davis had told the inquest: “I can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the trust for not keeping us safe. Mrs Davis continued: “The thing I cannot process is that I have lost my healthy, full-term son. I feel as if my son was taken from me in a circumstance that, in my personal and professional opinion, was completely preventable. Read full story Source: ITVX, 14 March 2024
  8. News Article
    Hospitals are cynically burying evidence about poor care in a “cover-up culture” that leads to avoidable deaths, and families being denied the truth about their loved ones, the NHS ombudsman has warned. Ministers, NHS leaders and hospital boards are doing too little to end the health service’s deeply ingrained “cover-up culture” and victimisation of staff who turn whistleblower, he added. In an interview with the Guardian as he prepares to step down after seven years in the post, Rob Behrens claimed many parts of the NHS still put “reputation management” ahead of being open with relatives who have lost a loved one due to medical negligence. The ombudsman for England said that although the NHS was staffed by “brilliant people” working under intense pressures, too often his investigations into patients’ complaints had revealed cover-ups, “including the altering of care plans and the disappearance of crucial documents after patients have died and robust denial in the face of documentary evidence”. Read full story Source: The Guardian, 17 March 2024
  9. News Article
    A doctor working at a women’s health clinic in Melbourne has been suspended as a regulator revealed it was aware of concerns about other practitioners there. The facility’s boss claims it is a “witch hunt”. It follows the death of 30-year-old mother Harjit Kaur, who died in January at the Hampton Park Women’s Clinic after what was described as a “minor procedure”. It was later identified as a pregnancy termination. The Australian Health Practitioner Regulation Agency (Ahpra) has confirmed Dr Rudolph Lopes’ registration had been suspended but did not reveal the reason behind the decision. His registration details show he was reprimanded in 2021 for failing to respond to the regulator’s inquiries. “[The regulator] has received a range of concerns about a number of practitioners associated with the Hampton Park Women’s Clinic,” Ahpra said in a statement. “[The regulator] has established a specialist team to lead a co-ordinated examination of these issues which involve multiple practitioners across a number of professions and across a number of practice locations.” Ahpra chief executive, Martin Fletcher, said he was “gravely concerned by the picture that is emerging.” “We have taken strong action to protect the public while our investigations continue,” Fletcher said. “National boards stand ready to take any further regulatory action needed to keep patients safe. “While the coroner continues to examine the tragic death of a patient, our inquiries are focusing on a wider range of issues that our investigations bring to light.” Read more Source: The Guardian, 15 March 2024
  10. News Article
    Alice and Lewis Jones were forced to watch their 18-month-old baby die in front of them after a failure by a scandal-hit NHS trust left him with a “catastrophic brain injury” following his birth. Their son Ronnie was one of hundreds of babies who have died following errors by Shrewsbury and Telford Hospital, where the largest NHS maternity scandal to date was previously uncovered by The Independent. Two years later, Mr and Mrs Jones are calling for the Supreme Court to overturn a controversial decision in February which ruled bereaved relatives could not claim compensation over the psychological impact of seeing a loved one die, even if it was caused by medical negligence. It comes after the trust admitted to failings in a letter to the parents’ lawyers. Ronnie’s birth in 2020 fell outside of the Ockenden review and his parents have warned it showed failures were still occurring despite warnings made during the inquiry. Within the Ockenden inquiry, multiple cases of staff failing to recognise and act upon CTG training were found, and the final report recommended all hospitals have systems to ensure staff are trained and up to date in CTG and emergency skills. The report also said the NHS should make CTG training mandatory and that clinicians must not work in labour wards or provide childbirth care without it. A CTG measures a baby’s heart and monitors conditions in the uterus and is an important measure before birth and during labour to observe the baby for any signs of distress. Ms Jones said: “We knew about the Ockenden review, but everything at Telford was new and so I think we just assumed that lessons had been learned, the same thing wouldn’t happen to us.” Ronnie’s parents are campaigning to reverse the Supreme Court which ruled that “secondary victims” – including parents who are not directly harmed by the birth – are not eligible to bring claims for psychiatric injury following medical negligence. Read full story Source: The Independent, 14 March 2024
  11. News Article
    A mental health trust linked to thousands of unexpected patient deaths repeatedly failed to act on coroners' safety warnings, campaigners say. BBC News has been given exclusive access to new evidence from coroners' reports gathered by a campaign group. It wants a criminal investigation into why so many patients died at Norfolk and Suffolk NHS Foundation Trust - and has sent police the evidence. Campaigners, including patients and bereaved families, claim it is failing to make vital safety improvements despite promising to do so. Last summer, a report found more than 8,000 mental-health patients had died unexpectedly in Norfolk and Suffolk between 2019 and 2022. This is defined as the death of a patient who has not been identified as critically ill or whose death is not expected by the clinical team. The new evidence, based on 38 coroners' prevention of future death (PFD) reports since 2013, suggests there were repeated warnings more patients could die unless safety issues were addressed, including: dangerously poor record-keeping and communication family concerns being ignored unsafe levels of staffing at the trust. And campaigners say the trust's failure to improve safety has led to more deaths. Read full story Source: BBC News, 12 March 2024
  12. News Article
    Bereaved relatives have accused ministers of dragging their feet over an inquiry into the death of almost 2,000 patients across NHS mental health trusts in Essex. The inquiry has still not started more than eight months after the announcement that it would be relaunched with beefed-up powers. In June last year, the government gave in to pressure from families and the then chair of the inquiry, granting it legal powers to compel witnesses to give evidence. In December, the new terms of reference were sent to ministers, setting out what the inquiry will investigate. But the terms of reference have yet to be approved by ministers, leaving relatives frustrated, with another “unnecessary” death reported a few weeks ago. Melanie Leahy, whose son, Matthew, died at the Linden Centre in Chelmsford in 2012, said: “I know that this inquiry, the first of its kind nationally, if carried out in a timely and comprehensively investigative manner, it has the power to prevent more deaths, not just in Essex but all over the UK. “Why am I and all the other bereaved families and injured individuals still waiting? Worse, why are we being met with such callous and terrifying indifference? Why are our legal team being ignored? We can only conclude that our government simply does not care. If the government continues to drag its feet in this way then they must be held to account for their failings. If there are more deaths during this interminable wait, this government needs to be held responsible.” Read full story Source: The Guardian, 12 March 2024
  13. News Article
    The Priory healthcare group has been fined more than £650,000 over the death of a 23-year-old patient who was hit by a train after absconding from a mental health hospital. Matthew Caseby, a personal trainer, was able to leave Birmingham’s Priory hospital Woodbourne by scaling a wall after being “inappropriately unattended” for several minutes in September 2020, an inquest jury ruled in 2022. The healthcare company pleaded guilty to a criminal safety failing linked to the death of a patient, breaching the 2008 Health and Social Care Act, at Birmingham magistrates court on Friday. The London-based provider was charged after an investigation into the death of Caseby conducted by the Care Quality Commission. Caseby’s father, Richard Caseby, who had been campaigning for a prosecution of the healthcare organisation, told the court the company attempted to “evade accountability for its gross failures”. In a victim impact statement which he presented as part of the prosecution on Friday, he said: “I found it unbelievable that a private company commissioned by the NHS to care for its most vulnerable psychiatric patients in the greatest crisis of their lives could be so cruel and resort to such desperate tactics to hide the truth.” Read full story Source: The Guardian, 8 March 2024
  14. Content Article
    Lewis Chilcott was 23 years old when he died at Royal Sussex County Hospital in Brighton. In this blog, his father Simon describes what happened to Lewis and how his family was treated by the hospital following Lewis’s death. Simon continues to call for greater transparency in the investigation process and improvements to the way hospitals engage with bereaved families.
  15. Content Article
    Adverse safety events (ASE) are common in paediatric out-of-hospital cardiac arrests (OHCA). This retrospective chart review study sought to estimate the prevalence of adverse safety events in children under age 18 experiencing OHCA. The researchers found that 60% of those children experienced at least one severe ASE, with the highest odds of ASE occurring when the OHCA was birth-related.
  16. News Article
    Coroners in England and Wales sent 109 warnings to health bodies and the government in 2023 highlighting long NHS waits, staff shortages or a lack of NHS resources, the BBC has found. The number of cases identified that were linked to NHS pressures was the highest in the past six years. Prevention of future death reports (PFDs) are sent when a coroner thinks action is needed to protect lives. About 35,000 inquests take place in England and Wales each year. In a fraction of those - about 450 - the coroner writes a PFD, or Regulation 28, report. The BBC analysed 2,600 PFDs - and supporting documentation - sent between 2018 and 2023. The proportion of the total number of PFD reports that referenced an NHS resource issue rose to one in five in 2023, from one in nine in the two years before Covid. Of the 540 reports written last year, 109 were found that highlighted a long wait for NHS treatment, a shortage of medical staff or a lack of NHS resources such as beds or scanners. Of these, 26 involved mental illness or suicide, and 31 involved ambulances and emergency services. The government says it "responds to, and learns from, every report". Read full story Source: BBC News, 8 March 2024
  17. Content Article
    This is my story, as a bereaved mother, about lessons I have learnt following the unexpected death of my previously well 25-year-old daughter Gaia in University College Hospital London (UCLH) in July 2021. I have written 11 patient safety lessons in the hope this helps other families be more assertive if they have a critically sick relative in hospital. Believe me, you must be pushy to be allowed into a hospital ward, even more so ITU. I went to visit my critically sick daughter at around 10am on a Sunday morning, but was not allowed on to the ward. A senior nurse told me to GO HOME using the 'Covid' excuse. I was shut out from the bedside of my critically ill only child. I have set up TruthForGaia.com to share learnings more widely. Please take a look. I hope sharing this may contribute to reducing avoidable deaths from brain conditions which can be only too easily assumed to be intoxication, especially on weekends. I believe raised intracranial pressure (high pressure in the skull) needs more awareness and training. When will UCLH hold a medical grand round on my daughter's case?
  18. Content Article
    Hospital nurse staffing, and the proportion of nurses with bachelor’s education, are associated with significantly fewer deaths after routine surgery, according to research published in the Lancet. A team of researchers conducted the study across nine European countries and found that a better educated nursing workforce reduced unnecessary deaths. Every 10%increase in the number of bachelor’s degree educated nurses within a hospital is associated with a 7% decline in patient mortality. Patients in hospitals, in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients, had almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients. The study shows that, in hospitals in England, an average only of 28% of bedside care nurses had bachelor’s degrees, among the lowest in Europe, which averaged 45%. The study shows that increasing the production of graduate nurses is necessary if the NHS is to realise the potential of lower patient mortality and fewer adverse patient outcomes.
  19. News Article
    Harry Miller was a popular teenager, appreciated for his sharp humour, ability to get on with anyone and eagerness “for the next adventure”. In the autumn of 2017, he was struggling with difficult thoughts and feelings of anger. Harry, who was 14 and lived in south-west London, confided his inner turmoil to friends and family. “I’m just having these anger rages,” he told his mother one day. “It’s like I just go crazy suddenly and I can’t control it. I don’t know what’s going on.” Two years previously, Harry had been prescribed the drug montelukast for his asthma. Unbeknown to his parents, a range of psychiatric reactions had been reported in association with montelukast treatment, including aggression, depression and suicidal thoughts. Harry’s parents, Graham and Alison Miller were not properly warned of the potential side effects. Their son was referred to the NHS child and adolescent mental health services in January 2018, but he missed an appointment because it was sent to the wrong person. On 11 February 2018, Harry was found dead in the family home, with an inquest later recording a verdict of suicide. He was described in a tribute by friends at St Cecilia’s Church of England school in Southfields, south-west London, as a “super star burning brightly”. Two years after his death, his father read an online warning about the adverse reactions involving montelukast by the Medicines and Healthcare Products Regulatory Agency (MHRA). It said these could very rarely include suicidal behaviour. Graham Miller said: “It is an absolute outrage that parents are being given psychoactive substances to give to their children without proper warning of the risk.” This weekend, the MHRA has confirmed that the drug is under review. A montelukast UK action group is calling for more prominent warnings of the drug’s possible side effects. Read full story Source: BBC News, 3 March 2024
  20. Content Article
    Dr Georgia Richards provides oral evidence to the UK Parliamentary Justice Select Committee's follow-up inquiry to the Coroner Service on 20 February 2024. Watch all of the evidence given by Georgia including: Part 1: Inconsistencies in coroner reports Part 2: Could sanctions improve the Coroner Service? Part 3: Improving the status and ability of coroner reports Part 4: Barriers to making changes Part 5: The potential future utility of the Tracker In part 1, shown in the below video, Dr Richards is asked what the evidence is for variation in writing coroner reports in England and Wales.
  21. 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
  22. 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.
  23. 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
  24. 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
  25. 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.
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