Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.

Concerns summary Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.

Concerns summary Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.

Concerns summary Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.

Concerns summary Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.

Concerns summary Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.

Concerns summary The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.

Concerns summary There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with dissemination, application, and applicability, particularly concerning informed consent.

Concerns summary Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, failed inter-team referral, and a prolonged lack of patient contact.

Concerns summary No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.

Concerns summary Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.

Concerns summary The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.

Concerns summary High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.

Concerns summary The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.

Concerns summary Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.

Concerns summary A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.

Concerns summary Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.

Concerns summary Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.

Concerns summary There was a lack of audit for complex 999/111 calls to identify learning opportunities, and call takers could inappropriately downgrade calls, potentially risking patient outcomes.

Concerns summary Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and an overstretched regional TVN service, led to delayed ulcer assessment.

Concerns summary An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.

Concerns summary There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.

Concerns summary Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.

Concerns summary The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.

Concerns summary Despite detailed recommendations from a hospital regarding Long QT Syndrome and drug-related cardiac arrest risks during anaesthesia, regulatory bodies (MHRA, NICE) have failed to update guidelines and product warnings.