Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive treatment based on their home address and time of stroke.

Concerns summary The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of early death due to delayed intervention.

Concerns summary Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to fatal delays.

Concerns summary Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for biliary sepsis collectively increased mortality risk.

Concerns summary The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.

Concerns summary Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.

Concerns summary Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.

Concerns summary The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.

Concerns summary Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.

Concerns summary Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.

Concerns summary Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.

Concerns summary The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.

Concerns summary Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from prior procedures.

Concerns summary Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE policy, highlighting a need for review.

Concerns summary The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded by false reassurance from NEWS scores, led to missed opportunities for earlier treatment.

Concerns summary Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.

Concerns summary Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of patient allocation because the patient remained in A&E, delaying critical review.

Concerns summary Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of bag searches during hospital transfers, contributing to her death by overdose.

Concerns summary An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially endangering future patients.

Concerns summary Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, delaying diagnosis. There is also no mandatory training for clinical staff on pressure ulcers.

Concerns summary The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and risking missed essential investigations.

Concerns summary Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside inadequate monitoring and care continuity, led to missed patient deterioration.

Concerns summary An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating sepsis protocol, inadequate monitoring, and delayed senior review, which significantly contributed to the patient's deterioration.

Concerns summary Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's hydration policy, leading to patient dehydration without clear accountability.

Concerns summary The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns about inadequate pre-treatment assessment and the need for mandatory First Aid training for chiropractors.