Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for specific requests. This issue, not fully addressed in an After Action Report, risks future diagnostic errors.

Concerns summary Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.

Concerns summary There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.

Concerns summary Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.

Concerns summary The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led to significant delays in diagnosis and appropriate antibiotic treatment.

Concerns summary Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests highlighting similar electrolyte monitoring failures.

Concerns summary Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney transplant patients.

Concerns summary Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.

Concerns summary Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed diagnosis and treatment of conditions like Acute Fatty Liver of Pregnancy.

Concerns summary Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this diagnosis for abdominal pain.

Concerns summary A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.

Concerns summary There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.

Concerns summary The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.

Concerns summary Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity for unwise decisions.

Concerns summary Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.

Concerns summary A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the root causes of these critical care gaps.

Concerns summary Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.

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.