Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in patient discussion and transfer.

Concerns summary Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.

Concerns summary Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to include all staff in notifications for highly transmissible cases.

Concerns summary A cost barrier in private healthcare discourages patients from crucial histological analysis of lesions, unlike NHS treatment where it's included, risking delayed cancer detection for those not meeting NHS referral criteria.

Concerns summary Dangerous junior orthopaedic staffing and inaccessible NEWS charts during ward rounds meant consultants were unaware of deteriorating patient conditions. There was also confusion among doctors regarding patient responsibility.

Concerns summary The Trust's investigation was incomplete and delayed, failing to address critical issues like inadequate staff observations and security breaches on a locked mental health ward. A dispute over permitted items and failure to escalate risk were also concerns.

Concerns summary A lack of clear guidance for prescribing intravenous Acyclovir, instead of ineffective oral medication, potentially led to incorrect treatment and preventable death for the patient.

Concerns summary A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.

Concerns summary A nationwide shortage of care providers and carers prevents commissioned care packages from being fulfilled, risking individuals not receiving necessary care with potentially fatal results.

Concerns summary Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.

Concerns summary Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.

Concerns summary Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.

Concerns summary A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.

Concerns summary Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was not a formal system, risking future harm.

Concerns summary A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to an ill-timed operation.

Concerns summary Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.

Concerns summary Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.

Concerns summary A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.

Concerns summary Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care needs beyond emergencies.

Concerns summary There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.

Concerns summary National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and treatments, resulting in poorer patient outcomes and advanced disease.

Concerns summary A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.

Concerns summary The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.

Concerns summary Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.

Concerns summary There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.