Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The mortality review was flawed, containing contradictory findings on avoidability, indicating a systemic failure in learning from deaths and raising risks for future patients.

Concerns summary Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.

Concerns summary A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an ongoing risk until a long-term IT solution is implemented.

Concerns summary NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.

Concerns summary Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.

Concerns summary The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, posing a risk to patient care.

Concerns summary The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.

Concerns summary A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as a laryngeal cancer red flag by healthcare professionals or the public.

Concerns summary The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients remaining unmonitored for extended periods.

Concerns summary The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.

Concerns summary A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.

Concerns summary Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.

Concerns summary The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.

Concerns summary Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the procedure's specialized nature.

Concerns summary A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.

Concerns summary There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.

Concerns summary In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.

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.