Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with a lack of internal incident review.

Concerns summary The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.

Concerns summary A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary or safety netting advice for a vulnerable patient.

Concerns summary Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service gaps for high-risk individuals.

Concerns summary Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and exacerbated mental health conditions.

Concerns summary Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current interim solutions still vulnerable to human error.

Concerns summary Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed to the patient's death.

Concerns summary Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies in covert bleeding.

Concerns summary The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe helicopter operations.

Concerns summary A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as required by protocol.

Concerns summary There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and documentation standards.

Concerns summary Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic issue risks future deaths.

Concerns summary A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to address this key issue, hindering learning from deaths.

Concerns summary Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new clinical settings.

Concerns summary Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. Poor record-keeping and absence of an internal investigation were also identified.

Concerns summary Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.

Concerns summary Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment for an aortic dissection, contributing to the patient's death.

Concerns summary A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance on historic data, and senior staff delayed emergency response despite prolonged abnormal CTG.

Concerns summary Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a different team and not returning to the operating hospital for essential follow-up.

Concerns summary Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.

Concerns summary Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training program and policy for preventing untrained bank staff from working are significantly delayed.

Concerns summary A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.

Concerns summary Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.

Concerns summary A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.

Concerns summary The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.