Coroner says hospital"s "failures" led to death of woman after caesarean

The death of a young mother just hours after she gave birth to her second son was a result of “failures, inadequate diagnosis and treatment” at the hospital caring for her, a coroner has said.

Frances Cappuccini, 30, died at Tunbridge Wells hospital in Pembury, Kent, shortly after giving birth to her son, Giacomo, by caesearean section. She suffered heavy bleeding and was anaesthetised, but went into cardiac arrest and died at 4.20pm on 9 October 2012.

The inquest at Gravesend old town hall in Kent heard Cappuccini lost more than two litres (around four pints) of blood after the C-section. She was subsequently operated on for a postpartum haemorrhage but never woke up from the anaesthetic. The inquest criticised the care given to her, including a piece of placenta that was left in her womb.

Senior coroner Roger Hatch said the caesarean section was not carried out with enough care and that checks should have been made to ensure nothing was missed. He said: “The result of this failure led directly to the subsequent series of events which tragically led to the death of Frances.”

Coroner says hospital"s "failures" led to death of woman after caesarean

Coroner criticises care of woman who died after kidney stone operation

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Third inquest into death of Carmel Bloom 14 years ago rules that ‘absences’ in routine aftercare contributed to cardiac arrest

A series of medical “absences” played a part in the death of a woman 14 years ago after a routine kidney stone operation, the third inquest into her death has ruled.

Carmel Bloom, 54, from Ilford, Essex, died on 8 September 2002, after surgery at the private Roding hospital in Ilford, where she worked as a health controller. She was taken to Whipps Cross intensive therapy unit (ITU) but died after her blood pressure fell and she suffered cardiac arrest.

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Coroner criticises care of woman who died after kidney stone operation

Neglect contributed to teenager"s death in psychiatric hospital, coroner rules

The lack of resources for children’s mental health services in the UK has been described as a “national scandal” after a coroner ruled that neglect and “continuing failures” at one of the largest mental health trusts in England contributed to the death of a teenage boy.

Christopher Brennan, 15, died after being found unconscious at Bethlem Royal hospital in south London in August 2014. He had been admitted to the psychiatric hospital’s adolescent unit six weeks earlier as his family and local mental health services felt unable to keep him safe at home.

Christopher had a history of harming himself, and a deterioration in his mental health over the two years before his death led to repeated hospital admissions.

The coroner found that no formal risk assessment was carried out during his stay at Bethlem hospital, which is run by South London and Maudsley NHS foundation trust, and there was no care plan in place, according to the charity Inquest, which is supporting his family.

South London coroner’s court heard he was also allowed access to a number of items in hospital which he used to self-harm.

On 31 August 2014 Christopher was found unconscious in a communal toilet and later died after suffering a cardiac arrest.

Handing down her ruling on Wednesday, the coroner, Selena Lynch, said: “Christopher’s actions were in part because of cumulative and continuing failures in risk assessment and management. His death was contributed to by neglect.”

The hospital trust offered its “sincere apologies” to his family and said it had reviewed its practices. A spokesman said: “Areas of learning for the trust were identified through a serious incident investigation and we have carefully reviewed our procedures accordingly.

“More recently, the service has been inspected by the Care Quality Commission and care was found to be of a ‘good’ standard. We hope this offers some reassurance to the family that lessons have been learnt from this very tragic event.”

Following the inquest Christopher’s family said: “Losing our beloved son and brother when he was just 15 years old was so painful. Losing him as a result of the hospital’s failure to protect his life is unbearable.

“Chris will never be forgotten and no other child should be allowed to die in this way.”

Christopher was one of at least 11 young people to die in psychiatric units in England between 2010 and 2014, according to Inquest.

Deborah Coles, the charity’s director, said: “Sadly, Chris’s death is not an isolated one. Incredibly, we find that no single body is responsible for collating, analysing or publicising these deaths and that these deaths are not being independently investigated.

“The lack of resourcing of child and adolescent mental health services across the country is a national scandal. The only possible response to this case and the growing public outcry and disquiet around mental health services for children and young people is for an urgent independent review. We call upon the government to now take this necessary step.”

Neglect contributed to teenager"s death in psychiatric hospital, coroner rules

Stroke victim failed by up to 36 "oblivious" medics - coroner

Dr Porter referred to as East Midlands Ambulance Services at one.53pm on November 5 and informed the operator his patient, who had previously suffered a stroke, necessary intravenous fluids when he arrived at hospital.

The ambulance failed to arrive, so Dr Porter dialled 999 to say it was an emergency, but the pensioner was not picked up right up until six.19pm since the dispatcher did not log the contact effectively.

When Mr Maltby ultimately arrived at the Queen’s Healthcare Centre (QMC) in Nottingham, he was admitted to Ward D57, but even more delays meant he was not offered fluids till 3.50am the following morning.

But even he was offered an intravenous drip, he was not offered the proper dose, which meant he acquired just two litres within 24 hrs as an alternative of the advised five litres.

Mr Maltby died the subsequent day on November 7 right after struggling kidney failure.

Recording a narrative verdict, Assistant Coroner Jane Gillespie condemned the healthcare personnel who handled Mr Maltby.

“These failures were far-reaching and impacted on all aspects of his care, from basic observations and recordings, to a delay in the escalation of his care and a failure to overview his problem by an appropriately senior physician when essential,” she mentioned.

“All the even though, Mr Maltby’s problem continued to deteriorate and those caring for him were oblivious to the same.

“During the time period of his admission, there had been several missed possibilities when the right treatment program could and must have been pursued. I uncover that had this been so, the end result could have been distinct.”

Speaking right after the inquest, Mr Maltby’s household criticised the medics who failed to care for their father.

“It is clear that the first reply from the ambulance services to our complaint about the delayed response to the get in touch with for an ambulance that they were ‘very busy’ was just paying lip services to their preliminary failings in this unfortunate and distressing series of events,” they mentioned in a statement.

“In his short and tragic time at the QMC, Stewart was dealt with by close to 36 men and women.

“Some have been obviously shown by the inquest to be hard-operating, committed individuals struggling in a extremely-pressured surroundings with tiny support from management in spite of direct and repeated requests for added help.

“Stewart was a character who produced us laugh with his mischievous sense of humour. He invested a lot of time caring for other individuals, typically to his personal detriment. Eighteen months on he is nevertheless very considerably missed by us all.”

Both the QMC and East Midlands Ambulance Services have apologised to the household.

Peter Homa, chief executive of Nottingham University Hospitals NHS Trust, mentioned: “We extend our condolences and reiterate our unreserved apologies to Mr Maltby’s household for the failings in our care and for letting them and their father down so badly.

“The absence of standard clinical observations, handovers among employees and failure to administer fluids appropriately meant Mr Maltby’s rapidly deteriorating issue was not acted on as it ought to have been.

“We have learnt from this unhappy and tragic situation and manufactured alterations to boost safety and outcomes for our future patients.”

A spokesman for the ambulance services extra: “The support we supplied to Mr Maltby fell brief of the large common our sufferers should assume, and we are extremely sorry about that.

“We have given that initiated a amount of changes and issued advice to all manage staff to guarantee that the exact same error can not be made when coming into bookings in potential.”

Stroke victim failed by up to 36 "oblivious" medics - coroner

Coroner raises considerations above child slings after boy suffocates

The death of a child who suffocated in a sling has prompted a coroner to increase issues about their safety.

Eric Matthews was 36 days outdated when he died on 1 January at Wonderful Ormond Street hospital in London from a fatal hypoxic brain damage. The coroner ruled that the death was induced by the baby getting carried in a material sling for the duration of a ten-minute stroll on Christmas Eve.

The paediatric pathologist Dr Mary Malone, who carried out a postmortem on the little one, mentioned that death in a sling usually occurred because the position of the infant inside it led to asphyxiation.

Malone explained she felt compelled to increase awareness of the potential dangers that slings could pose to infants soon after finding there had been at least six connected deaths in the Uk and sixteen in the US and Canada. The situations prompted the US Customer Item Safety Commission (CPSC) to advise caution to dad and mom using slings for infants younger than four months.

The coroner, Dr Richard Brittain, recorded a verdict that said: “Eric Matthews died from the consequences of a cardiac arrest which on the stability of probabilities resulted from asphyxia whilst becoming carried in a sling. There is nothing to suggest that the use of the sling was inappropriate or incorrect.”

The coroner created an official prevention of future deaths report on the danger of baby slings, which he requested be sent to Dr Rosemary Scott, a senior pathologist at University College hospital. Scott contacted Malone because she was investigating the possible of a review on sling deaths a handful of many years in the past. She has considering that located completing the research unfeasible and declined to comment.

Eric’s mom, Marriane Matthews, mentioned at the inquest that all the little one books she had go through advised her a material sling, which held him against her breast, was the safest spot for her little one.

The Royal Society for the Prevention of Accidents (RoSPA) supplies advice that states suffocation can arise in two ways.

“A sling’s fabric can press towards a baby’s nose and mouth, blocking the baby’s airways and causing suffocation. Secondly, there are hazards when softer slings are utilized if the infant is cradled in a curved position, nestling beneath the parent’s chest or close to their stomach. Infants do not have sturdy neck management, which indicates that their heads are much more probably to flop forward, which can restrict their ability to breathe.”

Sheila Merrill, public well being adviser at the RoSPA, stated: “We advocate using a carrier that keeps the newborn baby solidly against the parent’s entire body, in an upright position. Dad and mom need to ensure that they hold their baby’s chin off their chest, trying to keep the airways clear for breathing.”

Kid death overview panels at local authorities are responsible for reviewing data on all kid deaths. Nonetheless, this data stays confidential and although the Workplace for National Statistics publishes information on kid mortalities, the RoSPA says this does not contain the particulars it calls for to identify the linked hazards.

10,000 little one slings have been recalled in Britain in 2010 soon after they had been linked to the deaths of three American babies. The child care business Infantino warned parents to end employing its SlingRider and Wendy Bellissimo designs soon after an investigation by US security officials.

The RoSPA said it was not aware of any deaths connected to infants travelling in prams. It said it was not calling for a ban or discouraging mothers and fathers from employing slings, which it says have turn into more and more popular.

The buyer magazine Which? says there are rewards to employing slings, this kind of as helping parents to bond with their little one, easing discomfort and delivering comfort for the parent.

Safety suggestions 1st published by the United kingdom Consortium of Sling Producers and Merchants consist of a five-stage checklist, recognized as TICKS, for mother and father utilizing slings:

• Tight


• In view at all occasions


• Near enough to kiss


• Maintain chin off chest


• Supported back
  
  

Coroner raises considerations above child slings after boy suffocates

Coroner warns of dangers of "internet myths" right after female dies from consuming vinegar in abortion try

An inquest into Mrs Furey’s death heard how she had attempted to check out her GP in a bid to organize an abortion, but locating the surgical procedure closed she made a decision to drink the vinegar.

The inquest in Manchester heard how Ms Chadwick gave a perplexing account to police about whether or not it was she or Mrs Furey who had discovered the vinegar bottle and poured the drink.

Detective Constable Matthew Bolger, who interviewed Ms Chadwick about what occurred, informed the coroner that there was nothing to propose she had learning issues.

He explained: “Had I known, we would have organized for a solicitor or suitable grownup to be existing in the course of the interview.”

Even so, coroner Nigel Meadows criticised the CPS decision to prosecute her for manslaughter, saying it was obviously Mrs Furey’s decision to consider the drink.

He said: “Even if she had poured the drink, it is difficult to see how a case could be produced.”

Giving a narrative verdict, Mr Meadows stated the mum’s try to induce an abortion have been misguided and sent a warning to any person tempted to follow world wide web “myths”.

He stated: “This was a wholly avoidable scenario.

“All Mrs Furey had to do was to go to her GP. Attempting to do this on the hoof with incorrect data was fraught with trouble.”

Speaking after the case, Ms Chadwick stated: “This has been a total nightmare for all of us.

“I’m glad it really is lastly come to an finish and I can now grieve effectively for my friend. Catherine can now rest in peace.”

Her solicitor Alex Preston, from Olliers, said: “The terrible tragedy was worsened by the determination of the CPS to prosecute my consumer for manslaughter – a prosecution that the loved ones never wished. We are delighted the coroner has supported this view.”

Catherine’s husband Craig stated: “I’m just glad the complete factor is more than. We can get on with our lives.”

Coroner warns of dangers of "internet myths" right after female dies from consuming vinegar in abortion try

Coroner: options had been lost in care of boy who died at Bristol hospital

There were “misplaced options” in the care of a 4-year-outdated boy who died as he was taken care of on a controversial hospital ward after a heart operation, a coroner has ruled.

During his inquest, Sean Turner’s dad and mom, Yolanda and Steve, claimed their son was let down by a shortage of workers and a lack of skills on ward 32 at Bristol royal children’s hospital. They said he was so desperate for water whilst he recovered from the operation that he resorted to sucking liquid from moisturised tissues.

Providing a narrative verdict, the Avon coroner Maria Voisin stated: “Sean Turner died on 15 March 2012 from complications from the operation undertaken on 25 January 2012.” She continued: “There had been lost opportunities to render health-related care or treatment method to Sean in this publish-operative time period.”

Nonetheless, the coroner stated she had not heard proof of any “gross failures to offer basic care” in Sean’s treatment on ward 32. She also mentioned that getting heard of the adjustments the hospital had produced she would not be creating a “prevention of potential deaths” report to the believe in, adding: “I am conscious that the trust has manufactured plenty of changes because Sean’s death and I do not consider that I need to make any report in connection with this matter.”

Soon after the hearing, the Turners heavily criticised the hospital. They explained: “At the time of Sean’s surgical procedure in January 2012, Bristol claimed to be a centre of excellence with a specialist cardiac unit.

“Even though Sean essential a high level of nursing consideration, at occasions on ward 32 he did not even get the most fundamental care. There was a lack of leadership, accountability and communication.”

They said what they had discovered about the hospital was “shocking and unacceptable”, incorporating: “There had been numerous missed options to rescue Sean from his desperate situation. In our opinion, Sean was in the incorrect hospital with the incorrect surgeon. We now have to try out and rebuild our lives with out our tiny boy.”

Ahead of the inquest, Mrs Turner tweeted: “two yrs ago today Bristol asked us to carry Sean in for his fontan [the heart process] he was so excited! Today two yrs later on we await anxiously his inquest verdict.”

For the duration of the hearing Mrs Turner claimed a medical doctor had stopped her and husband, Steve, from looking for the suggestions of a retired Fantastic Ormond Street hospital surgeon since “he would by no means go to London for a 2nd view”.

She mentioned: “Sean was deteriorating. We could see it but nobody listened to us. We asked so numerous occasions and so a lot of personnel – from ward medical doctors, outreach nurses, cardiac liaison nurse and the nurses – if Sean could go back to intensive care as he had been far better there. We have been informed no beds or that merely he was not vital ample.

“Sean had escalating heart fee, was constantly being sick and was turning into so chronically dehydrated he was grabbing tissues utilized to amazing his forehead and sucking the water out of them. Our little boy was switching off, in horrible pain, struggling to breathe.”

Mrs Turner, a foster carer, mentioned nurses did not react to automated alarm calls on her son’s monitoring gear, carry out regular checks or fill in his record charts.

“No one seemed to assist. Nurses have been concerned but they appeared also occupied to give the time necessary to care for Sean at the level he essential,” she mentioned.

“Each nap he had I sat and cried as I felt so desperate and so helpless. Why would no one pay attention? We will in no way neglect the days on ward 32 and can in no way understand how a little one can be left to endure for so prolonged.”

Ward 32, the children’s cardiac ward, was severely criticised in October 2012, when the Care Quality Commission located there have been inadequate well-experienced nurses for the variety of individuals and issued a warning recognize requiring University Hospitals Bristol NHS foundation trust to consider quick action, which it did.

An inquest on yet another boy, Luke Jenkins, 7, who died in April 2012 soon after being taken care of on the ward, heard complaints strikingly similar to the Turners’ at the end of final yr. Up to 10 households, including people of Sean and Luke, are believed to be taking legal action towards the trust.

Two much more inquests involving youngsters treated at the hospital are scheduled for next month and March.

Mrs Turner, from Warminster, Wiltshire, informed the inquest she grew to become so upset on a single event that her husband advised her to depart so that Sean would not see her anguish. When she returned her son was surrounded by medical professionals obtaining suffered a cardiac arrest. The boy survived and Mrs Turner said they asked if he could be transferred to yet another hospital but were informed he was too poorly. Nor would they let the parents to have a second view, she claimed.

Later he suffered what his mom described as a “severe brain bleed” and doctors advised his parents there was absolutely nothing far more they could do. Mrs Turner stated they cuddled him and explained goodbye. “Sean fought so hard. There had been so many missed options,” she stated.

Throughout the inquest a senior nurse conceded there had been “deficiencies” in the care that Sean obtained whilst on ward 32.

William Booth, who is the matron and lead nurse for paediatric crucial care solutions, stated: “I can accept there have been deficiencies in care and that the [staffing] ratios could have been much better.

Booth outlined the modifications that had been created on ward 32, this kind of as strengthening staffing amounts, coaching, communication with dad and mom and the setting up of a large dependency unit inside of the ward.

He explained that inside the newly developed 5-bed higher dependency unit there was a ratio of patients to nurses of 2:1 and throughout the remainder of the ward it was now three:1.

Robert Woolley, chief executive of the University Hospitals Bristol NHS basis believe in, apologised to the Turners.

He mentioned: “The coroner has heard that their son Sean was born with a quite uncommon and complex heart situation and was undergoing a process which carries a known risk of death.

“But the inquest has also highlighted some missed possibilities in the care we gave to Sean when managing his post-operative issues and shortcomings in our communication with the loved ones.

“I would like to provide my sincere apologies to Mr and Mrs Turner for the extra stress that we have caused them in relation to Sean’s death.

“We are always improving our companies and we have produced substantial adjustments given that Sean was on the ward in early 2012. Regardless of Sean’s sad death, our outcomes are comparable to other national centres for this kind of surgery.

“We will, of course, proceed to reflect on Sean’s death, the coroner’s conclusion and the evidence heard more than the final seven days and we will guarantee we have identified all achievable lessons for potential care of kids like Sean.”

Mr and Mrs Turner explained: “We stay concerned that the dangers to sufferers at Bristol could still be really genuine. We have not noticed enough proof to persuade us that the lessons of Sean and Luke Jenkins’ deaths, much less than a month apart, have been learnt.”

Coroner: options had been lost in care of boy who died at Bristol hospital