Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.

Concerns summary The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.

Concerns summary A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.

Concerns summary Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect patient scores and policy non-adherence.

Concerns summary A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.

Concerns summary Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.

Concerns summary HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included inadequate medical training and supply restocking.

Concerns summary Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, bed rails were misused, and no protective measures were implemented post-fall.

Concerns summary Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct proper in-room checks, relying instead on distant sightings.

Concerns summary A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical review for an elderly patient. This raises concerns that other healthcare professionals may similarly underestimate the severity of head injuries.

Concerns summary The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.

Concerns summary Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.

Concerns summary Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.

Concerns summary Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.

Concerns summary The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.

Concerns summary The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an uninvolved nurse practitioner, insufficient safety netting, and failure to commence heparin despite a DVT/PE differential posed significant risks.

Concerns summary Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.

Concerns summary Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for national guidelines to ensure consistent, timely treatment.

Concerns summary Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.

Concerns summary The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.

Concerns summary The Trust failed to adhere to both NICE guidelines and its own internal policies concerning cancer screening, referrals, diagnosis, and treatment.

Concerns summary The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.

Concerns summary The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.

Concerns summary A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge without formal mental health aftercare or family guidance on relapse signs.