Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting atypically.

Concerns summary Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.

Concerns summary The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.

Concerns summary Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.

Concerns summary Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.

Concerns summary The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.

Concerns summary Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community wound care access further exacerbated health risks.

Concerns summary A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.

Concerns summary Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.

Concerns summary The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that steps have been taken to ensure proper documentation and consideration of these measures.

Concerns summary Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in patient discharge from hospitals.

Concerns summary Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.

Concerns summary Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to escalate urgency upon re-referral.

Concerns summary Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the provision of neurology advice and overall patient management.

Concerns summary Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.

Concerns summary Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.

Concerns summary The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.

Concerns summary Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the death.

Concerns summary Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.

Concerns summary The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.

Concerns summary Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability team.

Concerns summary Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents effectively.

Concerns summary A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.

Concerns summary Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on a strike day.

Concerns summary A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.