Brighton & Hove

Concerns summary Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.

Concerns summary The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.

Concerns summary Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by community mental health workers.

Concerns summary Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.

Concerns summary A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.

Concerns summary No specific concerns were detailed in the provided text for this report.

Concerns summary No specific concerns or systemic failures were detailed in the provided text.

Concerns summary The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.

Concerns summary The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.

Concerns summary Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.

Concerns summary Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.