Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.

Concerns summary The hospital failed to implement learning from a previous similar death, indicating a lack of updated teaching or protocols for recognising and managing aortic dissection presentations.

Concerns summary Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an inappropriate surgical technique.

Concerns summary Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. Surgeons were restricted in their choice of appropriate medical equipment.

Concerns summary Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and controlled drug management systems were ineffective.

Concerns summary Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future deaths.

Concerns summary Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current training's coverage of wrong-way driving risks.

Concerns summary The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.

Concerns summary National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused critical delays in treatment and assessment for life-saving surgery.

Concerns summary Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs remain incomplete months after recommendation.

Concerns summary The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.

Concerns summary A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and poor record-keeping also contributed.

Concerns summary District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.

Concerns summary Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual inaccuracies.

Concerns summary The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks for timely delivery and cross-referencing.

Concerns summary The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex foreign body removal. A lack of urgency and failure to recognise her deteriorating clinical condition contributed to critical delays.

Concerns summary Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, and policy for 1:1 observation is confusing, leaving a critical protocol gap.

Concerns summary Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack of electronic alert systems and over-reliance on unreliable verbal communication.

Concerns summary Clinicians lacked awareness of a rare drug complication, consent processes omitted crucial risks, and there was no clear guidance on discontinuing long-term medication for patients in remission.

Concerns summary Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is a medical emergency, leading to missed physical health assessments.

Concerns summary Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing a risk of future deaths.

Concerns summary A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge summary, leading to delayed care.

Concerns summary Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting patient safety.

Concerns summary A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.

Concerns summary Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were concerns. There were also unaddressed issues with medication ordering and insufficient training for agency staff.