Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to missed critical health issues.

Concerns summary Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential mental health treatment.

Concerns summary A shortage of suitable supported accommodation, coupled with poor communication, inadequate discharge planning, and insufficient risk assessment processes, compromised care for an individual with Asperger's Syndrome.

Concerns summary Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.

Concerns summary The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.

Concerns summary GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from services.

Concerns summary Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration risks.

Concerns summary Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.

Concerns summary Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.

Concerns summary Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.

Concerns summary Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant demand.

Concerns summary Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.

Concerns summary Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.

Concerns summary A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths due to delayed diagnosis and treatment.

Concerns summary Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP trainees were identified.

Concerns summary The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend analysis.

Concerns summary A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency assessment referral was made.

Concerns summary Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.

Concerns summary There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to national guidelines on this crucial patient information.

Concerns summary A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.

Concerns summary Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a lack of cover during a consultant's annual leave, putting patients at risk.

Concerns summary The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.

Concerns summary An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.

Concerns summary Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to the patient's death.

Concerns summary The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.