Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians and consideration of two escorts for patient safety.

Concerns summary Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.

Concerns summary A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.

Concerns summary A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like necrotising fasciitis.

Concerns summary Ineffective referral and incident reporting systems, poor communication with families, and significant delays in providing first aid after patient falls highlight systemic failures in care and oversight.

Concerns summary Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, hindering investigation.

Concerns summary Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.

Concerns summary A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.

Concerns summary Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.

Concerns summary A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.

Concerns summary Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.

Concerns summary A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.

Concerns summary No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.

Concerns summary Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.

Concerns summary Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.

Concerns summary There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.

Concerns summary Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.

Concerns summary Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.

Concerns summary Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and lack of Trust-wide learning from errors.

Concerns summary Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.

Concerns summary Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.

Concerns summary The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing and effective care escalation.

Concerns summary The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.

Concerns summary Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.