Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by monthly checks to go unnoticed.

Concerns summary Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, poor information sharing, and unclear responsibility during patient transfers in crisis.

Concerns summary Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in portering, ward nurse responsibilities, and unclear clinical accountability. The incident was also inappropriately downgraded.

Concerns summary A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low moods and his subsequent death.

Concerns summary Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.

Concerns summary Persistent, unaddressed systemic failures at the Trust include poor communication, inadequate supervision, incorrect early warning scores, and delayed action on patient deterioration, compounded by challenges from split-site operations.

Concerns summary No specific concerns regarding future deaths were detailed in the provided text, only contact information.

Concerns summary The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments after self-harm incidents. There was also an over-reliance on inpatient status as a protective factor and a lack of clarity in observation policies.

Concerns summary The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure to properly investigate a patient arrest raised serious safety concerns.

Concerns summary Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.

Concerns summary Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.

Concerns summary Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.

Concerns summary A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting with a non-smoking policy.

Concerns summary Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, despite the time-sensitive nature of the condition, likely contributing to death.

Concerns summary The acute psychiatric ward lacked specialist provision for young adults, and internal investigations into deaths were compromised by a lack of independence and transparency due to being conducted by directly involved staff.

Concerns summary The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their prior successful use in airway obstructions.

Concerns summary Deficiencies in staff understanding of mental capacity, best interests meeting management, and Deprivation of Liberty Safeguarding procedures led to inaccurate decision-making and documentation.

Concerns summary Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited means.

Concerns summary Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.

Concerns summary Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent experience for an essential procedure.

Concerns summary Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.

Concerns summary The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.

Concerns summary Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review and analgesia.

Concerns summary Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and effective treatment of suspected sepsis.

Concerns summary Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall and subsequent death.