Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.

Concerns summary The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that steps have been taken to ensure proper documentation and consideration of these measures.

Concerns summary Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in patient discharge from hospitals.

Concerns summary Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.

Concerns summary The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of improvements from an agreed action plan was demonstrated.

Concerns summary Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to escalate urgency upon re-referral.

Concerns summary Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the provision of neurology advice and overall patient management.

Concerns summary Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.

Concerns summary Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.

Concerns summary The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.

Concerns summary Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the death.

Concerns summary Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.

Concerns summary The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.

Concerns summary Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed to a fatal outcome.

Concerns summary Primary care failed to recognise a patient's learning disability as a factor in non-engagement, resulting in no direct communication or involvement from the learning disability team.

Concerns summary Datix reports were not completed timely, subjected to automated approval, and used templates, leading to incomplete information and missed opportunities to investigate patient safety incidents effectively.

Concerns summary A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.

Concerns summary Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on a strike day.

Concerns summary A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.

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.