Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.

Concerns summary Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to an increased risk of falls.

Concerns summary A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery of prescribed medication and the accuracy of medical records.

Concerns summary The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information being disseminated to GPs.

Concerns summary Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.

Concerns summary An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low blood pressure, compromised patient safety.

Concerns summary Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.

Concerns summary Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely ill babies in ED compromise patient safety.

Concerns summary A lack of automatic cardiology referral procedures led to sub-optimal cardiac failure management, and poor inter-departmental communication caused delayed and uncoordinated wound care.

Concerns summary Poor and inconsistent record keeping on a frailty unit, including lack of documentation for patient behaviour and professional assessments, prevented effective management and communication. There was also no system for agency staff to access policies.

Concerns summary A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. This poses a significant widespread risk to patients.

Concerns summary There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and operation of the Adult Critical Care Service Cymru for urgent patient transfers.

Concerns summary There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process for patients with hydrocephalus shunts, risking fatal outcomes.

Concerns summary Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also communication failures, insufficient telephone support, and an ongoing national mental health bed shortage.

Concerns summary Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little meaningful reflection or remediation followed her death.

Concerns summary The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.

Concerns summary Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of complications.

Concerns summary A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.

Concerns summary Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.

Concerns summary Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding single anticoagulant use.

Concerns summary GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT systems.

Concerns summary Significant national shortages of qualified immunology staff lead to prolonged patient waiting times and treatment delays, posing risks to patient health.

Concerns summary The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the death.

Concerns summary Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.

Concerns summary A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information risked proper task prioritization.