Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk patients.

Concerns summary The concerns text for this report is incomplete, so specific issues cannot be identified.

Concerns summary The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.

Concerns summary Healthcare staff failed to recognize a critical condition requiring immediate resuscitation and delayed alarm response due to assumptions. Agency staff had limited access to telephones for emergencies.

Concerns summary A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.

Concerns summary There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, leading to a lack of clarity in patient care and planning.

Concerns summary The concerns text for this report is incomplete, so specific issues cannot be identified.

Concerns summary Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to critical delays in emergency response and hospital transfer.

Concerns summary There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.

Concerns summary Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.

Concerns summary The provided text did not detail any specific concerns or systemic failures.

Concerns summary Deficiencies included inadequate observation charts, poor staff training on critical care teams, communication issues, flawed blood administration systems, and significant failures in escalating clinical concerns.

Concerns summary The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.

Concerns summary The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.

Concerns summary Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's condition. These delays significantly reduced her chances of survival.

Concerns summary The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of decisions. Additionally, a necessary consultant-led out-of-hours rota for post-surgery patients was not yet implemented.

Concerns summary The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.

Concerns summary Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.

Concerns summary There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.

Concerns summary Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of missing a fracture outweighs radiation exposure risk for elderly patients.

Concerns summary The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve systems for acting on discharge summaries regarding patient medication.

Concerns summary Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.

Concerns summary Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.