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Content ArticleOn 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.
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News Article
Council warned over broken alarm after woman dies
Patient Safety Learning posted a news article in News
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 -
News Article
Ambulance response warning after woman's death
Patient Safety Learning posted a news article in News
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 -
Content ArticleOn 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.
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News Article
Three staff disciplined over death at ‘culture of impunity’ trust
Patient Safety Learning posted a news article in News
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 -
Content ArticleOn 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.
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Content ArticleOn 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.
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News Article
Woman bled to death after hip replacement operation
Patient Safety Learning posted a news article in News
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 -
Content ArticleKerri 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.
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News Article
Block on data sharing contributed to death
Patient Safety Learning posted a news article in News
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 -
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.
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News Article
Seven more avoidable sepsis deaths spark coroner warnings
Patient Safety Learning posted a news article in News
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 -
News Article
Concerns at Nottinghamshire hospital after baby's sepsis death
Patient Safety Learning posted a news article in News
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 -
Content ArticleTommy 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.
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Content ArticleIn 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.
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News Article
Mental health trust failed to heed safety warnings, campaigners say
Patient Safety Learning posted a news article in News
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 -
News Article
Coroners' death reports reveal rise in NHS warnings
Patient Safety Learning posted a news article in News
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 -
Content ArticleDr 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.
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Content ArticleNicholas 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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News Article
Newly installed EPR contributed to A&E death, warns coroner
Patient Safety Learning posted a news article in News
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 -
Content ArticleOn 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.
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Content ArticleOn 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.
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News Article
Cancer patient went year without check-up, inquest told
Patient Safety Learning posted a news article in News
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- Posted
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Content ArticleThomas 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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Content ArticleThe National Coronial Information System (NCIS) is an online repository of coronial data from Australia and New Zealand.
