Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical risk has been addressed.

Concerns summary An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic failures in patient assessment and incident learning.

Concerns summary A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk of future deaths.

Concerns summary A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of prescribing without adequate patient context.

Concerns summary The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.

Concerns summary Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on 20-year-old evidence.

Concerns summary A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, inappropriate detention, and ultimately contributed to his death.

Concerns summary Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.

Concerns summary The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.

Concerns summary Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.

Concerns summary A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an ongoing risk until a long-term IT solution is implemented.

Concerns summary NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.

Concerns summary Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.

Concerns summary The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, posing a risk to patient care.

Concerns summary The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.

Concerns summary A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as a laryngeal cancer red flag by healthcare professionals or the public.

Concerns summary The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients remaining unmonitored for extended periods.

Concerns summary The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.

Concerns summary A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.

Concerns summary Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.

Concerns summary The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.

Concerns summary Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the procedure's specialized nature.

Concerns summary A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.

Concerns summary There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.

Concerns summary In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.