Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.

Concerns summary Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.

Concerns summary A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.

Concerns summary Hospital staff lacked proficiency in timely TIA Clinic referrals. Additionally, out-of-hours stroke care lacked commissioned stroke consultant input, adversely impacting patient treatment outcomes.

Concerns summary A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.

Concerns summary Ambulance service triage for Acute Behavioural Disturbance suffered from incorrect call categorisation and confusing, inconsistent training. Police training for Special Constables on ABD recognition also needs addressing.

Concerns summary Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.

Concerns summary Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.

Concerns summary The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.

Concerns summary The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.

Concerns summary The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.

Concerns summary The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it is standard practice.

Concerns summary There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in patients being monitored for clozapine.

Concerns summary The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate risk register.

Concerns summary Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.

Concerns summary The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, and transfer criteria between services are unclear.

Concerns summary The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.

Concerns summary The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.

Concerns summary Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic record accessibility.

Concerns summary The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.

Concerns summary Inconsistent and partially completed fluid/diet charts, confusion regarding dietary intolerances, limited suitable food options, and unrecorded external food intake hindered accurate nutritional monitoring.

Concerns summary Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a high-risk patient.

Concerns summary The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed sepsis diagnosis.

Concerns summary Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.

Concerns summary Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.