Brighton and Sussex University Hospitals NHS Trust
PFD Addressee
Reports: 36
Earliest: Feb 2014
Latest: 16 Jun 2022
PFD Reports
36 resultsJames Manning
Historic (No Identified Response)
2022-0179
16 Jun 2022
West Sussex
Child Death
Community health care and emergency services related deaths
Concerns summary (AI summary)
There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.
Steven Costello
All Responded
2021-0095
31 Mar 2021
West Sussex
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff training.
Action Taken
(AI summary)
The Royal Sussex County Hospital has updated the Emergency Department documentation to include clear guidelines for assessing the risk of self harm and suicide, with prompting questions and a traffic light system; training on the updated documentation has been delivered to all Emergency Department staff.
Frances Gibb
All Responded
2019-0422
10 Dec 2019
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.
Action Taken
(AI summary)
The Trust disputes that lessons haven't been learned regarding NEWS, citing the implementation of electronic patient observations (Patientrack) in all adult and paediatric inpatient areas since July 2019, with Maternity and ED to follow. All Radiologists have been reminded to look at the SMA, the protocol has changed to enable better visualization and overnight scans are reviewed by a Consultant the following morning.
Jean Waghorn
Historic (No Identified Response)
2019-0361
25 Oct 2019
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There were unnecessary and inappropriate transfers between hospitals, and the Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored, despite previous regulation 28 reports concerning the Transfer Policy.
Ioannis Avgousti
All Responded
2019-0135A
24 Apr 2019
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Action Taken
(AI summary)
The Trust has already taken several actions, including ensuring compliance with NICE guidelines for allergy management, incorporating a reaction tool into prescription charts, rolling out an electronic NEWS recording system, expanding the Critical Care Outreach service, and reviewing practices for preventing fatigue in junior doctors.
Kenneth Whittington
All Responded
2019-0049
14 Feb 2019
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.
Action Taken
(AI summary)
Brighton and Sussex University Hospitals NHS Trust has shared the inquest findings widely within the Trust, appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning and the discharge planner template is being revised to make it clearer and easier to use and record the key information.
Kalma Ram-Henman
All Responded
2018-0306
23 Oct 2018
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.
Action Taken
(AI summary)
Brighton and Sussex University NHS Trust conducted team meetings and a Serious Incident Review Meeting to address inadequacies in the patient's care. They issued a Trust Safety Alert instructing staff not to use the 'once-only' section of the drug chart for infusions, and implemented a new system for Acute Medicine Consultants to cover telephone calls.
Joan Blaber
All Responded
2024-0090
1 Oct 2018
West Sussex, Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.
Action Taken
(AI summary)
The Trust has revised COSHH procedures with updated folders and training that includes anonymised inquest evidence. The roles of Hosts and Housekeepers have been split and clarified and Datix incident reports are being reviewed and recoded.
Ronald Harman
Historic (No Identified Response)
2018-0234
19 Jul 2018
Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Rita Giles
Historic (No Identified Response)
2018-0224
11 Jul 2018
Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Barry Tucker
All Responded
2018-0018
17 Jan 2018
Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No specific concerns were detailed in the provided text.
Action Taken
(AI summary)
The Trust will not accept bookings for major urology cancer surgery patients on the private patient unit. The urology specialty will conduct documentation audits to identify themes and improvements, and agree a process for ensuring Electronic Discharge notification is signed/checked by a senior doctor.
Paul Gander
Historic (No Identified Response)
2024-0092
8 Dec 2017
West Sussex, Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.
Roger Saxby
Partially Responded
2017-0365
8 Dec 2017
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.
Noted
(AI summary)
St George's argues that thrombolysis was commenced as soon as practically possible and that the transfer back to RSCH was done with the patient's full agreement; transfers will only take place in exceptional circumstances after due consideration.
Patricia Webb
Historic (No Identified Response)
2017-0130
20 Apr 2017
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.
Ronald Bennett
All Responded
2017-0097
5 Apr 2017
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There are serious delays in ambulances arriving at the scene of an incident.
Action Planned
(AI summary)
The Trust is implementing several measures to improve emergency care performance, including expanding the emergency floor with an Urgent Care Centre, reviewing service provision at Princess Royal Hospital, implementing the SAFER care bundle, and expanding discharge capacity. They have also agreed and implemented a new clinical handover protocol with SECAMB. A new joint Standard Operating Procedure was developed in partnership with BSUH in March 2017, providing more clarity around the handover process and responsibilities, including escalation triggers, leading to improved performance in handover delays.
Paul Barber
All Responded
2017-0184
2 Mar 2017
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.
Action Taken
(AI summary)
Brighton and Sussex University Hospitals NHS Trust has circulated a message to staff about correct containers for sterile body fluids, altered the lab SOP to include an educational message when the wrong container is received, and discussed the case at a clinical governance meeting to improve prioritization of urgent follow-ups.
Raymond Pollard
All Responded
2017-0023
25 Jan 2017
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised the patient's health.
Action Planned
(AI summary)
The Trust's Head of Nursing reviewed the concerns and will share the learning with staff in Respiratory Medicine through sessions focusing on discharge procedures, responding to changes in patient NEWS scores, and appropriate documentation. Mr Pollard's care will be explored again at the next Respiratory Morbidity and Mortality Meeting and raised at the Trust-wide Deteriorating Patient Steering Group meeting.
Mary Muldowney
Historic (No Identified Response)
2016-0440
8 Dec 2016
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, despite the time-sensitive nature of the condition, likely contributing to death.
Leslie Lerner
Historic (No Identified Response)
2016-0487
28 Oct 2016
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review and analgesia.
Diana Ritchie
All Responded
2016-wp25376
18 Aug 2016
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Mrs Ritchie was recovering from major surgery and on her second day post operatively was suspected of having an Ileus.
1 response
from Brighton and Sussex University NHS Trust
Christine Street
All Responded
2016-0177
10 May 2016
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.
Action Taken
(AI summary)
Brighton and Sussex University Hospitals NHS Trust held study days for nurses on LBAW covering topics including Deprivation of Liberty, falls prevention, one-to-one care, and end of life care, after the inquest. An audit has been carried out of every patient specialled and the findings are being collated for action.
Jack Molyneux
Historic (No Identified Response)
2016-0168
29 Apr 2016
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
VERONICA HAMILTON-DEELEY, LLB_.
Geoffrey Moyse
Partially Responded
2016-0067
19 Feb 2016
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report raises concerns that were not detailed in the excerpt.
Action Planned
(AI summary)
Brighton and Hove Integrated Care Service used Mr Moyes' case as an anonymised example for discussion with their Patient Safety Group. They are ensuring all teams who offer patient choice are implementing protocols for when patients choose to delay their care. The CCG has issued a performance notice to Optum (Referral Management System provider) and is closely monitoring their performance. They will also review service specifications with independent sector providers to ensure clarity around handling incidental findings of cancer and links to multidisciplinary teams.
Marion Howes
Historic (No Identified Response)
2016-0046
11 Feb 2016
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
No specific concerns text was provided to summarise.
Brian Shillinglaw
Historic (No Identified Response)
2015-0427
6 Nov 2015
Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The provided text is incomplete and does not contain specific concerns.