Latest news with #PreventionofFutureDeath
BBC News
29-07-2025
- Health
- BBC News
Man with cancer died after delay in treatment
A coroner has written to a health board after delays to a cancer patient's treatment breached the Suspected Cancer Pathway time limit Wynne Tatchell died on 9 April 2024 at Princess of Wales Hospital in Bridgend. An inquest into Mr Tatchell's death found he died from the natural cause of pneumonia having undergone treatment for squamous cell carcinoma which had returned at the time of Coroner Aled Gruffydd is calling for answers about delays to staging and the treatment phase of his care. In a Prevention of Future Death's report, Coroner Aled Gruffydd said that the "delay in providing treatment more than minimally contributed" to his death. The coroner was told Mr Tatchell was referred to Morriston Hospital on 12 April 2023 by his dentist following the discovery of an ulcer in the lower left jaw. The referral was classed as an urgent suspected cancer (USC) and he was seen at the outpatients clinic on 28 April was suspected he had a squamous cell carcinoma but it needed to be confirmed by a biopsy, which took place on 18 May 2023, with the results returning on 30 May as a moderately differentiated squamous cell Tatchell returned to hospital again on 19 and 29 June for CT and MRI scans. His care was transferred when he saw a consultant on 6 July and 27 July to discuss treatments, which would consist of surgery and due to theatre capacity he did not undergo surgery until 13 week prior to the surgery, it was discovered Mr Tatchell's cancer had spread and was area was operated on but by February 2024 and with Mr Tatchell complaining of pain in his neck, specialists found the cancer had was readmitted to hospital on 8 March and subsequently died one month later. Writing to the chief executive of Swansea Bay Health Board, Mr Gruffydd concluded that "the delay in providing treatment more than minimally contributed to the deceased's death".The Suspected Cancer Pathway, introduced in Wales in 2019, required a suspected cancer to be diagnosed and staged within 31 calendar days of the date of referral. It also states that for treatment to commence within 62 calendar days from the date of referral. "In this case the diagnostic and staging phase was completed in 97 days from the date of referral and treatment commenced within 144 days of the date of treatment." Mr Gruffydd said that since then there had been evidence of improvement in theatre capacity and the addition of a consultant maxillofacial oncological surgeon appointed. However, he added that in May 2025, two associate medical directors expressed concern to the clinical lead for radiology that delays to staging scans were causing unnecessary risk in aggressive cancers that were at risk of progression and Gruffydd said he was concerned that delays in staging scans were allowing such cancers to progress to the point that they are "unresectable, resulting in poor prognosis for patients and reducing survivability rates and life expectancy".Swansea Bay Health Board has been asked to comment.
ITV News
12-06-2025
- Sport
- ITV News
Ricky Hatton backs calls for kickboxing to be made safer after 15 year old dies in unofficial match
Former professional boxer Ricky Hatton has backed calls for kickboxing to be made safer after the death of a 15-year-old at an unofficial match last year. Alex Eastwood, from Liverpool, was a world champion with five gold medals and had fought in hundreds of matches during his career, including the World Kickboxing Championship in Orlando in 2023. He was due to travel to Portugal to represent Great Britain. But in June last year the sport he loved cost him his life. Alex had fought three individual rounds of a bout at a kickboxing gym in Platt Bridge, Wigan on June 29, 2024 before becoming seriously unwell. His father Stephen Eastwood was watching and knew straight away that something was wrong. "It was just a chaotic scenario": Alex's dad Stephen Eastwood recounts running into the ring to help his son He was taken to Royal Albert Edward infirmary in Wigan and then transferred to the Royal Manchester Children's Hospital (RMCH) after he was found to have a bleed on the brain. Alex underwent surgery but died in hospital on July 2, 2024. Today an inquest into his death found that Alex died through misadventure. Coroner Michael Pemberton also said neither Alex, nor his parents appreciated the dangers of the 'chaotic and somewhat disjointed' approach to children involved in combat sports. The coroner cited the lack of minimum standards around combat sports and said the planning and lack of risk assessment before the fatal bout was 'sub optimal'. The fight was unofficial or unsanctioned which means organisers weren't obliged to meet stringent safety measures met by Kickboxing GB - the sport's main governing body Alex's family, who live in Fazakerley in Liverpool, say more needs to be done to improve safety for children taking part in contact sports like kickboxing, and that both official and unofficial matches should be obliged to meet a minimum standard. Mr Eastwood met with Ricky Hatton at the two-weight champion's gym in Hyde. Hatton kickboxed as a child before realising boxing was his true talent and believes that in any fighting sport involving children the safety of fighters must be paramount. What safety guidelines are currently in place for contact sports involving children? Ahead of the inquest HM assistant coroner Michale Pemberton raised concerns over a lack of regulatory framework or guidance in terms of any child contact sports. He took the unusual step of sending a Prevention of Future Death (PFD) to Lisa Nandy, the Secretary of State for Digital Culture, Media and Sport (DCMS). Contact sports such as boxing, kickboxing and MMA aren't legally required to meet a minimum standard when it comes to official or unofficial matches where physical force may be used between or against a child participant. Official matches will be governed by individual sport associations such as Kickboxing GB or England Boxing. However, if a match is unofficial or unsanctioned, there is no guideline of what minimum standard must be met to provide safeguarding for a child participant. That means arrangements for each and every contact sport contest involving a child is left to the judgement of an organiser which includes: Ian Hollett from Hurricane Combat and Fitness, Alex's kickboxing club responded to the inquest's findings. He said: 'We are utterly devastated by the loss of Alex who truly was a wonderful, kind and exceptionally talented boy. "He was a beautiful and loving soul who was the epitome of excellence, humility and generosity. Our thoughts and prayers are with his family and we are deeply sorry for their loss. "We thank the coroner for his thorough investigation and fully welcome any recommendations made that will help prevent another tragedy like this happening again.' David Pearson a solicitor at Broudie Jackson Canter, who is representing the club said: 'This unimaginable tragedy has brought into sharp focus the need for further regulation in all combat sports involving children across the country. "We would welcome any future recommendations made.' What do Kickboxing GB say? A spokesperson for Kickboxing GB said: 'Following the Inquest this week into the tragic death of Alex Eastwood, the thoughts and sympathies of Kickboxing GB are with Alex's family and friends at this incredibly difficult time. "The Inquest has heard just how talented a kickboxer Alex was, and how much of a loss his family and friends have suffered. "Whilst the event which Alex attended was not a Kickboxing GB sanctioned event, we have provided assistance to the Coroner throughout this Inquest and we welcome his findings. "Kickboxing GB remains committed to ensuring that participation in the sport is as safe as possible and will consider the findings of the Coroner carefully and review policies and procedures accordingly." What does the government say? The government says it's not their job to directly regulate sport. Responding to the Prevention of Future deaths report Culture Secretary Lisa Nandy said: "I would like to extend my deepest sympathies to Alexander's family and friends. "The safety of those participating in sport has to be paramount. "Whilst the government does not, and should not, directly regulate sport it is clear lessons must be learned. "My Department is exploring ways to improve the safety and welfare of children in martial arts and I have asked Sport England to work with the Martial Arts Safeguarding Group and other relevant combat sport stakeholders on this vital issue." What do Sport England say? Sport England are the arms-length body of government responsible for growing and developing grassroots sport. They aren't regulators themselves but do work with many national governing bodies to ensure high safeguarding standards are embedded across the sector. In a statement they told ITV News: 'We extend our deepest sympathies to Alexander's loved ones. "This tragic loss is a reminder to anyone taking part in or organising events that safety in sport must be the number-one priority. "Sport England is not a regulator of sport, but we work with many national governing bodies to ensure high safeguarding standards are embedded across the sector. "Sadly, unregulated activities which are not sanctioned by a governing body can be dangerous, and lessons must be learned. "As part of the Martial Arts Safeguarding Group, which was formed in 2018, we work with combat governing bodies and the NSPCC's Child Protection in Sport Unit. "As part of this, the group is looking to develop and build on existing educational resources to empower parents and carers with the questions to ask when their child is taking part in any event or competition.'
The Irish Sun
21-05-2025
- Health
- The Irish Sun
Boy, 15, collapsed and died during football game at school just days after doctors wrongly diagnosed him with asthma
A TEENAGE boy who collapsed and died during a football game at school was wrongly diagnosed with asthma just days before, an inquest heard. Trafford , on November 5 last year. Advertisement 2 Jake Lawler was misdiagnosed with asthma a month before his death Credit: 2 The 15-year-old collapsed and died during a football game Credit: Facebook The court heard a month before his death he attended Wythenshawe Hospital complaining of shortness of breath while playing football. The inquest was told Jake, from Sale, had collapsed on the pitch on October 13, 2024. Alison Mutch, senior coroner for Manchester South, has now written in a Prevention of Future Death report. She warned how medical professionals incorrectly diagnosed the teenager with exercise induced asthma. Advertisement Read More According to the report, an "abnormal ECG" and an "exercise induced syncope episode", were not recognised or followed up on. Medical history provided by Jake's father was also "not assessed correctly". The coroner concluded the abnormal ECG in combination with the teen's collapse "should have resulted in him being referred for an inpatient paediatric review and further testing". And, when Jake was discharged, his ECG results were wrongly recorded as coming back "normal". Advertisement Most read in Football Jake's GP prescribed him medication for the misdiagnosed asthma, but it did not seem to have any effect on the youngster. A test for asthma was also conducted five days after Jake collapsed. But the nurse referred him back to a doctor as they did not think he suffered from the condition. The 15-year-old tragically died from a biventricular arrhythmogenic cardiomyopathy just a month later. Advertisement The coroner wrote in her report: " It is probable that he would not have died on the day he did had the correct actions been taken. " Jake's collapse was incorrectly attributed to his exercise induced asthma." In her report, four areas of concern were highlighted to help prevent future deaths. She stated Jake's ECG results were "key warning signs" that shouldn't have been missed, whether due to training or insufficient medical equipment. Advertisement Another "red flag event" laid out was "no clear national guidance" on the route to take after a paediatric exercise induced syncope. The third point spotlighted covered asthma treatment prescribed by the GP, which failed to elevate Jake's symptoms, and the asthma assessment. "Jake was assessed by his GP practice using the national asthma scoring system," wrote the coroner. "However, the scoring system does not appear to facilitate scoring for exercise induced asthma. Advertisement "In Jake's case the readings and answers pointed to a well-controlled asthma. "This was at variance with the fact that his history indicated that he was continuing to struggle with his breathing when exercising and meant he did not trigger as a concern. "This was exacerbated by the normal peak flow readings taken at rest which gave a falsely reassuring picture." The coroner added there was a "lack of curiosity" and a "lack of appreciation" regarding how limiting the assessment was. Advertisement "In my opinion action should be taken to prevent future deaths, and I believe you and/or your organisation have the power to take such action," she continued. Manchester University NHS Foundation Trust and GP Surgery have until July 4 later this year to respond to the report. Jake's school said at the time of his tragic death: "Our school community was absolutely devastated by the loss of one of our much loved and precious students, Jake Lawler, who recently passed away in tragic circumstances. "As a school, we keep his family and friends in our thoughts and continue to support our students and staff during this incredibly difficult time. Advertisement "We would also like to take this opportunity to share a link to Jake's memorial fund, set up by his family to raise awareness of a very worthy cause - CRY (Cardiac Risk in the Young). "The money will go towards raising awareness of young sudden cardiac death as well as supporting the families affected, supporting their screening programme and funding research and pathology." What is biventricular arrhythmogenic cardiomyopathy ACM is a condition where the cells in your heart muscle don't stick together properly. The walls of your heart can become weak and blood may not be pumped as well as it should. Your heart has four chambers. The top two are called the atria and the bottom two are called the ventricles. ACM can affect one or both of your ventricle chambers. Jake suffered from biventricular arrhythmogenic cardiomyopathy, meaning it affected both. ACM is usually a genetic condition which means if one of your parents have it, you have a 50/50 chance of inheriting the faulty gene that could cause ACM. ACM symptoms palpitations (a pounding or fluttering feeling in your chest or neck) feeling lightheaded fainting feeling breathless or shortness of breath abnormal heart rhythms (when your heart beats too fast, too slow or irregularly) swollen ankles, legs or tummy area feeling pain or discomfort in your chest. How is ACM diagnosed? Chest x-ray Cardiac MRI scan ECG (electrocardiogram) Exercise test Echocardiogram How is ACM treated? Medication Pacemaker ICD (implantable cardioverter defibrillator) Cardioversion Catheter ablation
Business Mayor
13-05-2025
- Health
- Business Mayor
Charity boss slams 'reprehensible' health trusts
Stuart Woodward BBC News, Essex Reporting from Lampard Inquiry Jamie Niblock/BBC Deborah Coles said the behaviour of some NHS trusts at inquests was 'reprehensible' Health trusts have repeatedly tried to prevent coroners from issuing Prevention of Future Death reports in order to protect their reputations, an inquiry has heard. Deborah Coles, director of the charity Inquest, told the BBC the 'reprehensible' behaviour was a pattern 'played out across the country' but was 'exemplified' in Essex. She gave evidence at the Lampard Inquiry, which is looking into the deaths of more than 2,000 people being treated by NHS mental health services in Essex between 2000 and 2023. Essex Partnership University NHS Foundation Trust (EPUT) has apologised to those affected. 'Angry and frustrated' In her evidence to the inquiry, Ms Coles said the 'lack of candour' on the part of mental health trusts in Essex was the reason a statutory public inquiry needed to be held. 'It's difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, which is ultimately about trying to safeguard lives in the future – and I find that reprehensible,' she said. 'We are talking here about trying to protect lives and also remember those who've died where those deaths were preventable.' Stuart Woodward/BBC The Lampard Inquiry is hearing evidence at Arundel House in London across several sessions in 2025 and 2026 Speaking to the BBC after giving evidence, Ms Coles said NHS trusts were more concerned about reputational damage than learning lessons. 'This goes to the heart of what I was talking about [in the inquiry]… the fact that trusts are more concerned with protecting their reputations than acknowledging the failings in their systems and processes and trying to do something meaningful about it,' she said. Ms Coles added that she was also angry and frustrated at a lack of political will from successive governments 'to ensure the change that is needed… to try and stop the appalling culture of defensiveness that we see from NHS trusts, exemplified by Essex'. 'NHS trusts try and argue with coroners that they've already implemented changes and that a report is not necessary,' she said, adding that it undermined potential for local and national learning. 'We need to be able to ensure that we're not talking about cut-and-paste action plans, but we can demonstrate that action has been taken and that recommendations are implemented.' A Department of Health and Social Care spokesperson said: 'It's crucial that every person affected by this ordeal has a right to tell their story. 'The inquiry has heard testimonies from many families, and we are confident that the inquiry will provide a valuable channel for them to have their voices heard.' PA Media Bereaved families were praised by Ms Coles for their 'incredible strength, courage and determination' The public inquiry is England's first into mental health deaths, with evidence being heard in London after sessions in September and November. Evidence will continue to be heard throughout 2025 and 2026, with Baroness Lampard's report due to be issued in 2027. EPUT chief executive Paul Scott has apologised for deaths under his trust's care. He said: 'As the inquiry progresses, there will be many accounts of people who were much loved and missed over the past 24 years and I want to say how sorry I am for their loss.' READ SOURCE
BBC News
17-04-2025
- BBC News
Surrey woman's holiday caravan death of prompts safety warning
The death of a Surrey woman in a caravan fire while helping her children escape has prompted a coroner's warning over fire safety Pingree, 42, from Thames Ditton, was described by her family as having a "brilliant mind" and "utterly devoted to her children". She died after the holiday caravan she was staying in caught fire in Saxmundham in Suffolk in July a Prevention of Future Death report Suffolk Coroner Darren Stewart found there is "substantial potential for short cuts and misunderstandings" in fire safety regulation for businesses providing accommodation. Mr Stewart said: "There is a lack of clear standards concerning what fire safety measures are required, how to assess what is to be applied, how to achieve that standard, and the assurance and enforcement mechanisms beyond this."Ms Pingree and her husband and two children had been staying at the Happy Days Retro Vacations caravan site with a group of caravan caught fire during the night from either an ember blowing from a nearby fire pit or a discarded cigarette or match, the inquest heard. Ms Pingree had stayed to help her children flee the burning coroner found that had the fire alarm worked it is likely it would have alerted the family early. The coroner found there is not any set guidance or format to conduct a risk assessment under the Fire Safety Order for proprietors. The Pingree family did not receive a safety briefing when they arrived, or when they were introduced to the caravan. Happy Days Retro Vacations closed after the fatal fire and its owners have declined to comment, according to Local Democracy Reporting Service.
