Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.

Concerns summary Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.

Concerns summary A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.

Concerns summary Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.

Concerns summary Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer protocols.

Concerns summary The absence of national regulation, clear training frameworks, and comprehensive competency assessments for Physician Associates creates significant patient safety risks and widespread role confusion.

Concerns summary A patient's one-to-one fall supervision plan was not documented in medical records, leading to its non-implementation and a fatal fall. This highlights a systemic failure in managing elderly patient fall risks.

Concerns summary A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks leads to delayed recognition and treatment, increasing fatality rates.

Concerns summary Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge and inadequate monitoring.

Concerns summary Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.

Concerns summary A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre capacity, increasing the patient's sepsis risk, leading to the patient seeking private care and subsequently dying from sepsis.

Concerns summary An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for emergency departments exacerbated this risk.

Concerns summary A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and capacity assessments across hospital transfers, hindering timely learning and comprehensive training.

Concerns summary The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.

Concerns summary A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.

Concerns summary Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells are functional are inadequate.

Concerns summary Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with previous PFD reports on unrecognised oesophageal intubation failing to prompt necessary changes.

Concerns summary The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.

Concerns summary Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain blood cancers, given international study suggestions.

Concerns summary The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to critical safety protocols despite training and previous PFD reports.

Concerns summary Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term steroid use, pose a fatal risk despite local improvements.

Concerns summary Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite the patient's history.

Concerns summary Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks in care continuity and increased risk, highlighting systemic hospital capacity issues.

Concerns summary Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.

Concerns summary Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.