Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff burnout and recruitment difficulties.

Concerns summary A significant delay in critical surgery was caused by NHS-wide understaffing, underfunding, and limited weekend cover, disadvantaging patients with injuries sustained on Fridays.

Concerns summary Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved staff training on recognizing and escalating high-risk pain symptoms was identified.

Concerns summary Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of understanding of the patient's condition.

Concerns summary Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly patients in the hospital.

Concerns summary There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is unavailable when needed.

Concerns summary The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy is needed to ensure patient safety.

Concerns summary Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general paediatricians having inadequate practical experience in neonatal resuscitation.

Concerns summary St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin inspections, and incident reporting. This indicates systemic governance and quality assurance deficiencies.

Concerns summary There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to community care, leading to potential gaps where high-risk patients' needs are not met.

Concerns summary The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.

Concerns summary Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.

Concerns summary A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.

Concerns summary Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.

Concerns summary The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.

Concerns summary Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.

Concerns summary A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.

Concerns summary Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.

Concerns summary Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout their inpatient stay.

Concerns summary A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic social care shortages.

Concerns summary There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to his death.

Concerns summary Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.

Concerns summary Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.

Concerns summary A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.

Concerns summary Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.