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Found 207 results
  1. Content Article

    Clinical Communiqué (June 2024)

    Anonymous

    Anonymous posted an article in Patient stories

    The Communiqués are an Australian not-for-profit group that develop, produce and distribute innovative and free electronic educational publications and podcasts on lessons learned from Coroners’ investigations into preventable healthcare-related deaths.
  2. Content Article
    On the 22 January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14 January 2024 at Homerton University Hospital.   The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6 January 2024, but it was not repaired or replaced. Sometime after 4.45pm on 11 January 2024 the deceased fell at home. She was found the next day by a carer, wearing her wrist alarm and taken to hospital where she died on 14 January 2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.
  3. News Article
    An assistant coroner has warned an east London council more people may die if it does not take action, after a "frail lady who was prone to falls" died of hypothermia at her home. Anoush Summers, 77, died in hospital in January after a fall days earlier. In a prevention of future deaths report, external, assistant coroner Edwin Buckett said Ms Summers' inquest concluded "the absence of a working wrist alarm prevented her from being found sooner than she was and probably contributed to her death". Ms Summers lived alone but received help from two carers from Supreme Care Services, and she was visited twice a day. After falling at home on 11 January, she was found the next day at 09:00 GMT wearing her wrist alarm and was taken to hospital. She died of hypothermia at Homerton University Hospital on 14 January. The assistant coroner said among issues he identified in her case "giving rise to concern" were: Her wrist alarm had been reported as broken and not working on 6 January, but "this was not replaced or repaired by the company engaged by the local authority", which meant Ms Summers could not call for help as "it did not work" None of the carers who attended her home after the wrist alarm broke on 6 January "ensured that steps were taken to replace the alarm" or reported the matter to the local authority The last carer to see her, who visited on 11 January, "was not aware that the wrist alarm did not work as she had not read the care notes", and "no clear instruction was given" about the extent to which carers should read these notes "None of the carers had been given any training, instruction or guidance on the testing of wrist alarms to ensure they worked properly when attending" There was not a "clear system identified between the company providing carers and the local authority as to the duties and responsibilities of each in the reporting of faults with wrist alarms" Read full story Source: BBC News, 26 June 2024
  4. Content Article
    This article published by The Justice Gap highlights new research that has revealed the psychological toll of the inquest system on people whose loved ones die in contested circumstances, including struggling with a complicated legal process and suffering due to cuts to the system.
  5. News Article
    Long waiting times at hospitals in the north-west of England are putting patient's lives at risk by holding up ambulance crews, a coroner has warned. It comes after the death of Bobilya Mulonge, who called 999 with breathing problems on 24 November 2022. She waited 72 minutes for an ambulance - four times longer than North West Ambulance Service's (NWAS) 18-minute target for her category of emergency call - which "probably contributed to her death", coroner Lauren Costello said. A NWAS spokesman said the service was "very sorry" an ambulance was unable to attend sooner and the service had made "significant" improvements since. A report by Ms Costello has been sent to the health secretary and NWAS and urges the region's health authorities to take action to prevent further deaths. She said evidence about ambulance delays revealed during the inquest had given rise to her concerns. "In my opinion there is a risk that future deaths could occur unless action is taken," she wrote. Dale Ollier, north-west regional organiser for Unison, which represents some ambulance staff, said backlogs in moving patients out of hospitals was having a "knock-on effect" at A&E, leading to a "bottleneck crisis". “We have patients that could be safely discharged but there isn’t anywhere to discharge them to because of the lack of capacity in social care." Ambulances were working "flat out", he added, but delays had lead to an "unbearable demand" on crews who were sometimes "tied up for several hours" waiting at hospitals. Read full story Source: BBC News, 20 June 2024
  6. Content Article
    On 24 May 2023 an investigation was commenced into the death of Bobilya Mulonge then aged 62 years. The investigation concluded at the end of the inquest on 19 April 2024. The conclusion of the inquest was a narrative conclusion that Mrs Mulonge died as a result of congestive cardiac failure against a background of hypertensive heart disease. Ambulance response times probably contributed to her death.     The medical cause of death being:   1 (a) Congestive Cardiac Failure (b) Hypertensive Heart Disease   II) Chronic Kidney disease and Type II diabetes mellitus.
  7. News Article
    The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
  8. Content Article
    The Voicing Loss project is a collaboration between the Institute for Crime & Justice Policy Research at Birkbeck, University of London, and the Centre for Death & Society at the University of Bath. The research was conducted from May 2021 to May 2024, with funding from the Economic and Social Research Council. The research examined the role of bereaved people in coroners’ investigations and inquests, as defined in law and policy and as experienced in practice. It also explored ways in which the inclusion and participation of bereaved people in the process can be better supported. A range of project outputs are available via the dedicated Voicing Loss project website. They include a short research summary, along with thematic research reports and policy and practice briefings. The website also has an information and resources section for the general public, and an Expert Insights blog to which many stakeholders have contributed.   Many of the study’s key findings, and the research context and methodology, are presented in the papers listed on the website. Implications of these findings for policy and practice are considered in a series of briefings also available through the website which you can access via the link below.
  9. News Article
    Three staff have been put on “improvement plans” after a patient’s death which a coroner said nurses had been dishonest about, HSJ has learnt. North East London Foundation Trust was heavily criticised over the death of Winbourne Charles at an inquest last year. Coroner Graeme Irvine said staff “had not told the truth” about how Mr Charles came to take his own life in an inpatient unit at Goodmayes Hospital, in east London. Two witnesses refused to give evidence, citing a rule that they could not be compelled to incriminate themselves. Mr Irvine recorded a verdict of “suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed”. His prevention of future deaths report also noted “observation records appeared to have been created utilising a ‘cut and paste’ function” while there were “factually inaccurate entries” stating Mr Charles “was alive and well” up to two days after his death. In comments reported by the Barking and Dagenham Post last year, Mr Irvine said: “I think witnesses who have given evidence to me in this inquest have not told the truth. “It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.” Read full story (paywalled) Source: HSJ, 14 June 2024
  10. Content Article
    On 11 April 2021 an investigation into the death of Winbourne Gregory Charles, aged 58, was carried out. Winbourne was admitted into hospital under section 2 of the Mental Health Act 1983 in November 2020 following an attempt to take his own life. In December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms, Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983. On 10 April 2021 Mr Charles was found unresponsive, suspended on the mental health ward. The Court returned a conclusion of:   “Suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed.”   Mr Charles’ medical cause of death was determined as 1a Suspension.
  11. Content Article
    On the 8 March 2023, an investigation commenced into the death of Christine Rita Booker, born on the 6th October 1943. The investigation concluded at the end of the Inquest on the 17 May 2024. The medical cause of death was: la Haemorrhagic shock   lb Iatrogenic injury of right pelvic blood vessels 2 The conclusion of the Inquest recorded that Christine Rita Booker died as a consequence of a complication of elective hip replacement surgery.
  12. News Article
    A 79-year-old woman bled to death following a hip operation after being rushed to a hospital which lacked a service to save her, a coroner has said. Christine Booker from Wareham died on 24 February 2023, the day after her hip replacement. Coroner Brendan Allen said she was initially transferred to Dorset County Hospital in Dorchester, which had no out-of-hours interventional radiology (an imaging procedure), before being sent to Royal Bournemouth Hospital. In a Prevention of Future Deaths report, he said patients in west Dorset faced a "potentially considerable and significant delay in the provision of urgent and life-saving treatment". Writing to Dorset County Hospital, external, the coroner said the lack of an out-of-hours service in Dorchester exposed patients to an "increased risk of death". Read full story Source: BBC News, 10 June 2024
  13. Content Article
    Kerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in two months. In March 2021 she complained of having per vaginal bleeding for six weeks and she was referred for an ultrasound. Due to her underlying ill health, she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home.
  14. News Article
    A surgeon who may have infected two new mothers with herpes has been granted anonymity during the inquests into their deaths in an "unprecedented" ruling. Coroner Catherine Wood said she made the decision because the surgeon's "apprehension" about being named when he stands as a witness would "likely impede his evidence in court" and affect his health. Mid Kent and Medway Coroners is investigating the cases of Kimberly Sampson, 29, and Samantha Mulcahy, 32, who both died in 2018 after the same obstetrician conducted their caesareans. They were treated 6 weeks apart in hospitals run by East Kent Hospitals University NHS Trust (EKHUT). On February 26 – the day before the inquest was due to begin and 16 months after it was first announced – EKHUT made a last-minute bid for anonymity covering the surgeon and a midwife also involved in both cases. The trust said they should not be named unless the inquest concluded they had passed on the infection, because of the "reputational damage" they would suffer, and because the surgeon's health was already being impacted by reports. Read full story Source: Medscape, 9 March 2023
  15. News Article
    A failure to share medical information between IT systems contributed to the death of a man in prison custody, a coroner has concluded. In a newly published report on the death of Finlay Finlayson at HMP Lewes in 2019, the coroner highlighted “information sharing” problems and “permissions issues” between the prison IT system and that of the man’s GP surgery. Mr Finlayson died from blood clots in his lungs, having suffered from multiple long-term health conditions including cancer during his life. At the time of his death in 2019, health services at HMP Lewes were provided by Sussex Partnership Foundation Trust, though they are now provided by the Practice Plus Group. According to the Prevention of Future Deaths report issued last month, coroner Laura Bradford heard evidence that Mr Finlayson’s care was affected by “confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne”. It appears the GP practice had not enabled sharing of the data, which would have been required for it to be accessed in the prison. Read full story (paywalled) Source: HSJ, 22 April 2024 Further reading on the hub: NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn? The digitalising of patient records — why patients MUST be involved
  16. Content Article
    'Vinney' died of pulmonary thromboemboli due to deep vein thrombosis with a background of metastatic carcinoma of the base of the tongue following cardiac arrest on 25 January 2019 at HMP Lewes (Cell 216 on C-Wing), whilst on remand. He was pronounced dead at 9.16 am. The jury considered that Vinney’s care was affected by the following issues, the absence of which may have delayed or changed the circumstances of his death. There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney’s own statements. Some poor record keeping on SystmOne and confusion over when to reference the system. This affected both plans and reporting of interactions. Failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare. This was particularly relevant between 21 and 24 January 19. In particular a lack of quantifiable evidence, e.g. NEWS scores or notes of proportionate follow-ups and recorded observations between 21 and 24/1/19 which may have allowed any deterioration in Vinney’s condition to be missed. On 25/1/19, there was a grave and unacceptable failure in communications with two or three emergency radios switched off in contravention of prison rules and protocols. This was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response, which may have been longer had it not been for decisive intervention from comms. This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney’s mental health were a factor, and should have been automatic on account of his head injury.
  17. News Article
    Preventable deaths of seven people from sepsis – including four children – have prompted coroners to flag major concerns about NHS services’ management of the condition. Since the start of March, six English coroners have sent formal warnings to trusts, NHS England and the government warning of systemic failures to spot sepsis and delays in administering antibiotic treatments. It comes after an HSJ investigation in February uncovered more than 30 avoidable deaths from sepsis, and undertook analysis of internal figures revealing repeated failures by NHS trusts to provide prompt treatment. Coroner warnings since March include: Two notices were sent this week by Nottingham assistant coroner Elizabeth Didcock to Sherwood Forest Hospitals Foundation Trust, raising concerns over its ability to provide safe paediatric care following the deaths of 10-week-old Tommy Gillman and five-year-old Meha Carneiro from sepsis; A warning from earlier in April criticising University Hospitals Birmingham FT for its failure to treat 56-year-old Tracey Farndon’s sepsis and low blood pressure. Read full story (paywalled) Source: HSJ, 17 April 2024
  18. News Article
    The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024
  19. Content Article
    Tommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.
  20. News Article
    Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified. From September, medical examiners will look at the cause of death in all cases that haven’t been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity. They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died. The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation. Health Minister, Maria Caulfield said: Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way. The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses. From 9 September 2024 it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny. Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for Royal College of Pathologists, said: “As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms. “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.” Read full story Source: Gov.UK, 15 April 2024
  21. 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.
  22. News Article
    Catherine O’Connor was 17 when she died, having lost 14 litres of blood during high-risk surgery on her back. At her inquest, the surgeon who operated on her, John Bradley Williamson, told the coroner the procedure at Salford Royal Hospital in Greater Manchester had “progressed uneventfully” and “the blood loss was perhaps a little higher than one would usually anticipate but was certainly not extreme”. The coroner recorded a verdict of death by misadventure. Now Greater Manchester police are examining O’Connor’s death, in February 2007, and whether Williamson misled the coroner during the inquest in September that year. Catherine's family are now demanding a new inquest into her death in 2007. This is because in the days after O’Connor’s death, Williamson sent an internal letter to the head of the hospital’s haematology department, Simon Jowitt, describing the surgery as “difficult” and having involved “a catastrophic haemorrhage”. Williamson had also ignored advice to have a second surgeon present during the operation. Officers led by Detective Inspector Michael Sharples have commissioned two expert reports and sought advice from the Crown Prosecution Service ahead of a meeting with the coroner, who has been asked to consider reopening O’Connor’s inquest. Read full story (paywalled) Source: The Times, 31 March 2024
  23. 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
  24. 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
  25. 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?
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