Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key risk factors.

Concerns summary Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient patient repositioning.

Concerns summary Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.

Concerns summary Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that hinder effective falls prevention.

Concerns summary Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.

Concerns summary Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.

Concerns summary Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after a fall.

Concerns summary Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.

Concerns summary Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their health.

Concerns summary Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail patients.

Concerns summary Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.

Concerns summary Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.

Concerns summary A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.

Concerns summary Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.

Concerns summary Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.

Concerns summary Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.

Concerns summary A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.

Concerns summary Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.

Concerns summary Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.

Concerns summary A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.

Concerns summary Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting observations, delayed diagnostics, and overall systemic communication and competency breakdowns.

Concerns summary Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was not followed, and staff lacked awareness regarding CT scan requirements.

Concerns summary Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding GP understanding, CRT prioritization, or triage effectiveness, causing patients to become seriously unwell before assessment.

Concerns summary The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical history, omitted the risk of death, and was signed while sedated.

Concerns summary Critical failures included unreliable recording of IV fluids, missed communication during triage, and contradictory medical notes. The incident investigation was inadequate, failing to address systemic issues or ensure timely corrective actions eight months post-death.