Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment and treatment according to their health needs.

Concerns summary A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, community and primary care teams lack training to identify critical deterioration in fracture patients.

Concerns summary Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates potentially critical treatment delays.

Concerns summary Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving a significant learning gap.

Concerns summary Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent with expected standards and poses a risk.

Concerns summary A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to wait in A&E.

Concerns summary Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.

Concerns summary A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and specialist consultation despite known risks.

Concerns summary Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug interactions), and the diagnosis of serotonin syndrome.

Concerns summary Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical reviews and urgent clinical assistance for a patient with a significant bleed.

Concerns summary Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading discharge summary and insufficient root cause analysis further compounded the issues.

Concerns summary Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance failed to identify and review a serious incident, compromising patient safety.

Concerns summary Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure medical emergencies.

Concerns summary Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also an over-reliance on private care with insufficient oversight.

Concerns summary Insufficient radiology slots for feeding tube replacements caused week-long delays and suboptimal nutrition for complex patients. There was also a lack of clear procedures for maintaining nutrition during these delays.

Concerns summary Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.

Concerns summary Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised patient care.

Concerns summary Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.

Concerns summary The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing patient records, risking missed reviews and unintended cessation of vital medications.

Concerns summary Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the 24-hour period only upon ward admission, despite long patient waits.

Concerns summary Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of preventable deaths for patients requiring timely hospital transfer.

Concerns summary Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of excessive post-dental procedure bleeding for these individuals.

Concerns summary DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.

Concerns summary Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.

Concerns summary An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early COVID-19 vaccination. The system lacked validation rules to challenge such data errors, contributing to his death.