Latest news with #PreventionofFutureDeathsReport
BBC News
26-04-2025
- Health
- BBC News
Reading surgeon suspended from duties after three deaths
A hospital consultant has been suspended from surgical duties after the deaths of three patients in three consultant Daniel McGrath ceased surgery shortly after operating on 52-year-old Lorraine Parker at Royal Berkshire Hospital in Reading in January a report on Mrs Parker's death, Senior Berkshire Coroner Heidi Connor said she had raised concerns about the surgeon with the General Medical Council (GMC).The hospital said Mr McGrath was still seeing outpatients under supervision, but had stopped surgical duties 10 months ago. Mrs Parker, a childminder, died in March 2024 after a surgical join leaked and was not quickly diagnosed and managed, the inquest medical experts were critical of her aftercare rather than the surgery itself, the coroner a Prevention of Future Deaths Report, Ms Connor said: "Lorraine Parker's death was the third in three months following surgery by the same consultant colorectal surgeon."She said one of Mr McGrath's previous patients, Michael Edwards, died in December 2023 following a "significant surgical error" when a healthy part of his bowel was removed instead of a cancerous an internal hospital review rated his care as either "good" or "excellent", the coroner Mrs Parker's case, the hospital found "no learning points", she added.A third patient died in March 2024, Ms Connor said. The coroner told Ms Parker's inquest: "Having conducted all three of these inquests and another earlier case back in 2018 [at a private hospital]... I am struck by the lack of reflection on the part of this surgeon."There has been throughout little acceptance of any of the issues and criticisms raised by different independent experts."I am concerned about the risk of future deaths should Mr McGrath continue to operate here or elsewhere."Ms Connor said the surgeon's case was her first ever referral to the added: "It appears that the option to return to operating remains open for Mr McGrath, even after a GMC notification by the trust with certain caveats and requirements in place before he may do so." A spokesperson for the Royal Berkshire NHS Foundation Trust, said: "The trust extends our sincerest condolences to Ms Parker's family."The consultant ceased surgical duties 10 months ago and we have worked closely with the Coroner and the GMC to provide them with assurance about measures put in place to oversee his work which has been restricted to outpatient work."We continue to monitor this arrangement and will implement any further recommendations made following this inquest."The provision of safe and high quality patient care is an absolute priority for the trust and all our clinicians work to rigorous protocols to ensure patient safety. "In 2024, Mr McGrath was ordered to pay £1.2m towards damages and costs following the death of his patient Simon Healey at Berkshire Independent Hospital in Reading. You can follow BBC Berkshire on Facebook, and X.
Telegraph
25-03-2025
- Health
- Telegraph
‘Handsfree breastfeeding' is unsafe, parents warned
Childbirth charities have warned parents that 'handsfree breastfeeding', carried out using a carrier or sling, is unsafe. The National Childbirth Trust (NCT) and the Lullaby Trust said they would be making a 'rapid change' to their breastfeeding guidance because of the risk of suffocation, as babies cannot lift their own heads if incorrectly positioned. It is especially dangerous for babies who are premature or have a low birth weight. Their statement follows the death of six-week-old James 'Jimmy' Alderman who was being fed in a sling by his mother, Ellie, as she moved around their home. Her sling was worn 'snugly', but not tightly, and although she could see his face, he was too far down for this position to be safe. The baby collapsed after five minutes and, despite resuscitation attempts, he died in the hospital three days later, on Oct 11 2023. Lydia Brown, the senior coroner for West London concluded that Jimmy suffered an accidental death as a result of hypoxic brain injury, out of hospital cardiac arrest and accidental suffocation. In a Prevention of Future Deaths Report, she said: 'Jimmy died because his airway was occluded as he was not held in a safe position while within the sling. 'There is insufficient information available from any source to inform parents of safe positioning of young babies within carriers and in particular in relation to breastfeeding.' Now, two leading childbirth charities have issued a joint response, and promised to inform those expecting a baby that hands-free breastfeeding is 'always unsafe'. The NCT, which provides classes for expecting parents, said babies should always be taken out of a carrier to feed and that the practice is also a trip hazard. It warned: ''Hands-free' breastfeeding or bottle feeding, where the wearer moves around and does other jobs while the baby is feeding, is unsafe.' George Alderman, Jimmy's father, said the move was a 'good first step' but 'mixed with sadness' as it took his son's passing for guidance to be changed. The sports writer, 38, said: 'We are really pleased that the Lullaby Trust and the NCT have updated their guidance, it was definitely something that through the inquest process we felt strongly about.' He described the guidance as a 'good first step', but added that there should be a warning about breastfeeding attached to sling labels. Acronym for safe positioning Babywearing is a popular parenting practice where a child is strapped into a harness or wrapped in a sling so they can be carried by a parent hands-free. Supporters of the technique, which has been practised around the world for a millennia, say it helps babies bond with their parents through close contact. A UK consortium of sling retailers and manufacturers have shared an acronym, Ticks, to establish safe positioning for babies in slings. The acronym created by the now disbanded group stands for Tight, In view at all times, Close enough to kiss, Keep chin off the chest and Supported back. The NCT previously said that you could breastfeed a baby in a sling but that the baby should be supported at all times. This advice was rated as 'unhelpful' by the coroner because it could not fulfil all of the Ticks requirements. She also noted there was no guidance in NHS literature on the subject. NHS England and the Department of Health and Social Care have since promised to make their advice on safe baby-wearing more accessible and linked to breastfeeding guidance. The joint response from the NCT, the Lullaby Trust and two other children's charities said: 'As charities with direct contact with new and expectant parents and families we see our role in preventing future deaths as key. 'We also noted, and share your views, that simple, consistent messaging would help families, and we are committed to supporting that goal wherever possible in our information and services for parents and families.'
BBC News
01-03-2025
- Health
- BBC News
Bournemouth: Teen died after healthcare 'catastrophes', says family
A teenager took his own life after a "catalogue of catastrophes" in his mental healthcare, his family has Channing, 18, also known as "Kieran", was found dead in his room at Arts University Bournemouth (AUB) on 27 January 2022.A coroner previously said there were "missed opportunities" by NHS trusts to teenager's parents, from Devon, said he was "left to his own devices" despite concerns for his safety. In a statement, the parents, who asked not to be named, expressed frustration over his mental health treatment from the age of said: "We were never advised how, as parents, we could help or manage his condition."In September 2021, he began his university course, shortly after making four attempts on his life and being diagnosed with emotionally unstable personality disorder (EUPD), they told the BBC."His care worker was supposed to have referred him to the Bournemouth mental health team but soon after went on long-term sick leave and never came back," they added. In January 2022, the student was detained in hospital in Devon again under the Mental Health weeks later, he returned to Bournemouth where fellow students reported concerns about him to AUB, his parents an NHS appointment days before his death was cancelled when he caught Covid, leaving him feeling let down, they said: "Although we had suspicions throughout his journey that the healthcare professionals could have done more, we were always trusting and hoping they were doing their best."It was only after the seven-day inquest that the coroner confirmed our doubts that... they could have done better."In a Prevention of Future Deaths Report, coroner Richard Middleton said the cancelled Bournemouth appointment was a "missed opportunity".He said the teenager's care after hospital in January 2022 was not properly planned and university welfare staff had no training in EUPD, otherwise known as Borderline Personality the university, Dorset Healthcare NHS Foundation Trust or Devon Partnership NHS Trust offered any comments when approached by the benches in the teenager's memory, paid for by well-wishers, have been placed at a school in Ottery St Mary and in Exminster where he grew you are affected by any of the issues raised in this story, support and advice is available via the BBC Action Line. You can follow BBC Dorset on Facebook, X (Twitter), or Instagram.
The Independent
28-02-2025
- Health
- The Independent
Coroner demands change after pensioner died following 10-hour ambulance wait
A coroner has demanded action following the death of a 79-year-old woman who had waited 10 hours for an ambulance. Diana Fairweather-Purkis died from multi-organ failure at the University Hospital of North Tees in Stockton, two days after she was eventually admitted. Teesside and Hartlepool Coroner Paul Appleton has written a Prevention of Future Deaths report, saying that more ambulance crews are needed to decrease wait times. He has also said there were 'excessive delays' in crews being able to hand over patients to hospital staff. The coroner has sent copies of the report to Ms Fairweather-Purkis' family, the Department of Health, NHS bosses, the North East Ambulance Service and the North Tees and Hartlepool NHS Foundation Trust. Following an inquest which concluded earlier this month, Mr Appleton concluded: 'Diana died due to multi-organ failure secondary to urosepsis. 'Diana's death was contributed to by: naturally occurring comorbidities, delays in ambulance attendance, and delays in the prescription and administration of antibiotics.' Mr Appleton found that a call to the 111 service was made at 10.14pm on September 30 2022 and an ambulance should have got to her within two hours. At almost 8am the next day, she had still not been seen by paramedics and the seriousness of her case was upgraded to a Category 2 with a target response time of 18 minutes. A crew arrived at 8.10am – nine hours and 56 minutes after the initial 111 call. She was taken to the University Hospital of North Tees, arriving at around 9am on October 1, where her condition deteriorated and she died on October 3. Mr Appleton outlined his concerns, saying: 'There is insufficient Ambulance Service availability/resource to enable ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times. 'There are excessive delays in ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff.' The report has been sent to the Department of Health, NHS England and NHS North East and North Cumbria Integrated Care Board for action. The ambulance service and hospital trust were sent a copy of the report as they were interested parties in the inquest. An NHS England spokesperson said: 'NHS England extends its deepest sympathies to the family and friends of Diana Fairweather-Purkis. 'We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course. 'We know too many people are waiting too long for an ambulance. 'NHS England is working with the Government and Ambulance Services to tackle this priority for the NHS, so patients get the help they need quicker.'
Yahoo
22-02-2025
- Health
- Yahoo
Hospital should 'take action' after fall death
A coroner has told a north London NHS trust it displayed "widespread communication issues" after an elderly patient died from an unwitnessed fall at a hospital. Carl Eastman, 96, suffered an irreversible bleed on the brain after falling in the enhanced care bay of the Royal Free Hospital in Camden on 28 July last year. An inquest into his death at Inner North London Coroner's Court heard Mr Eastman had been admitted to the hospital five days earlier following a fall at home, but he fell again in a hospital ward on 25 and 28 July. The Royal Free London NHS Foundation Trust has been contacted for a response. Mr Eastman was transferred to the hospital's enhanced care bay "where he should have been kept under constant observation", assistant coroner Ian Potter said in a prevention of future deaths report. His third unwitnessed fall, in the early hours of 28 July, occurred "at a time when a member of staff should have accompanied him", the coroner said. Mr Potter added there was "evidence of what I considered to be 'widespread communication issues' in the care provided to Mr Eastman" which posed "a risk that future deaths could occur unless action is taken". This included staff on the ward incorrectly telling the on-call doctor on 28 July that nobody had fallen which meant Mr Eastman's condition was not reviewed, he continued. Communication between the ward staff and medical staff was "not good" and evidence provided at the inquest revealed there were "deficiencies in basic record keeping", the coroner added. Mr Potter said: "There was clear evidence that the trust has put extensive measures in place to address the issue of staff having not followed the trust's own post-fall procedures and protocols. "However, I am concerned that the issue may not be limited to just those particular protocols and may be indicative of a wider skills or knowledge deficit." Evidence also appeared to show "a lack of professional curiosity on the part of some staff members", he added. Copies of the coroner's Prevention of Future Deaths Report were sent to the chief executive of the Royal Free London NHS Foundation Trust, Mr Eastman's family and the Care Quality Commission. Woman died after clot was not diagnosed - inquest Mum says NHS unit involved in son's death not safe Coroner's Court Royal Free London NHS Foundation Trust
