Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A housing association was unaware of the UK Power Networks Priority Services Register, risking vulnerable residents not receiving enhanced support during power outages.

Concerns summary NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical records, risking inappropriate clinical decisions.

Concerns summary A critical echocardiogram result was not reviewed by a clinician for months, as no system ensured timely review when appointments were cancelled, and no pathway existed to flag urgent findings.

Concerns summary The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.

Concerns summary GPs and internal hospital staff experienced significant difficulties contacting the Medical Assessment Unit and A&E to pre-alert them about seriously unwell patients, causing dangerous delays in assessment.

Concerns summary A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include lack of referral guidance, limited physiologist knowledge, and inconsistent clinical data communication.

Concerns summary An unchanged ICB form, intended for financial decisions, incorrectly includes an allergy section. This led to inaccurate clinical records and suboptimal patient care, with a risk of recurrence as the process remains unaddressed.

Concerns summary A lack of national guidelines exists for assessing paediatric heart conditions like myocarditis, coupled with insufficient awareness of Parvovirus. Locally, critical radiology reports were delayed, metabolic acidosis causes were not fully explored, and documentation of observations and handovers was incomplete.

Concerns summary A national shortage of donor livers, particularly for "super urgent" children, is exacerbated by clinical guidance. This has led to extended waiting times, significantly increasing the risk of lives being lost due to organ unavailability.

Concerns summary Sepsis was not recognised or managed correctly, consultant review was delayed and hampered by poor communication, and junior staff felt unable to challenge decisions, leading to critical omissions in care.

Concerns summary Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin post-fall.

Concerns summary The falls risk assessment was inaccurate, not updated, and documentation was incomplete.

Concerns summary A patient with advanced dementia became dehydrated and severely constipated at a care facility, despite recognized needs for dietary, fluid, and personal care support.

Concerns summary A GP made critical decisions without full information, and there was no effective process to ensure updated or additional reports reached the GP before patient management decisions.

Concerns summary There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.

Concerns summary There is no nationally validated sepsis screening tool for Paediatric Emergency Departments, and the trust's own tool lacks consistent application between departments.

Concerns summary A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient care.

Concerns summary There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently clear, especially for postpartum women.

Concerns summary Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.

Concerns summary Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed critical care.

Concerns summary Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.

Concerns summary Ineffective electronic patient records failed to flag critical medication information, and poor communication led to anticoagulation being administered against patient wishes, without specialist stroke input.

Concerns summary A GP practice failed to adequately scrutinise abnormal blood test results, missing a critical referral for specialist cardiac assessment despite clear laboratory advice.

Concerns summary The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about Serious Incident Report procedures.

Concerns summary Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the Trust.