Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.

Concerns summary Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.

Concerns summary Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.

Concerns summary Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.

Concerns summary Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.

Concerns summary Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.

Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.

Concerns summary The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.

Concerns summary There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.

Concerns summary A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.

Concerns summary Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.

Concerns summary Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.

Concerns summary The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.

Concerns summary The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.

Concerns summary Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her injury.

Concerns summary Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.

Concerns summary There was a critical failure to provide out-of-hours access to flexible sigmoidoscope equipment, and no clear, accessible protocol for staff regarding such access even 18 months later.

Concerns summary Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering seamless patient transitions.

Concerns summary Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.

Concerns summary A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent observations.

Concerns summary No attempt was made to obtain historical input or information from private clinicians when the patient reverted to NHS mental health care, missing potentially helpful treatment guidance.

Concerns summary Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly delegated capacity and best interests assessments by untrained staff.

Concerns summary Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.

Concerns summary Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.

Concerns summary Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.