Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient's one-to-one fall supervision plan was not documented in medical records, leading to its non-implementation and a fatal fall. This highlights a systemic failure in managing elderly patient fall risks.

Concerns summary A widespread lack of understanding and routine training among medical staff regarding air embolism signs, symptoms, and risks leads to delayed recognition and treatment, increasing fatality rates.

Concerns summary Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge and inadequate monitoring.

Concerns summary Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.

Concerns summary A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre capacity, increasing the patient's sepsis risk, leading to the patient seeking private care and subsequently dying from sepsis.

Concerns summary The Trust failed to prevent a predictable and avoidable fall, leading to death. Furthermore, its governance systems inadequately identified and reflected upon these care failings, preventing effective remediation.

Concerns summary An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for emergency departments exacerbated this risk.

Concerns summary A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and capacity assessments across hospital transfers, hindering timely learning and comprehensive training.

Concerns summary There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex mental health needs.

Concerns summary The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.

Concerns summary A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.

Concerns summary Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells are functional are inadequate.

Concerns summary Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with previous PFD reports on unrecognised oesophageal intubation failing to prompt necessary changes.

Concerns summary The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.

Concerns summary Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain blood cancers, given international study suggestions.

Concerns summary The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to critical safety protocols despite training and previous PFD reports.

Concerns summary Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term steroid use, pose a fatal risk despite local improvements.

Concerns summary Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite the patient's history.

Concerns summary Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks in care continuity and increased risk, highlighting systemic hospital capacity issues.

Concerns summary Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.

Concerns summary Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.

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.