Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, led to misdiagnosis and potential unsafe discharge.

Concerns summary A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.

Concerns summary Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.

Concerns summary Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.

Concerns summary There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, leaving the patient vulnerable. This oversight was exacerbated by poor note-taking.

Concerns summary The ward suffered from a lack of clear leadership, insufficient staffing, and uncoordinated patient care. Critical failures included a missing notes protocol, and no clear procedure for managing refusal of vital checks or escalating severe hyperglycaemia.

Concerns summary Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider the effects of warfarin on patients.

Concerns summary Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.

Concerns summary Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The Medical Registrar failed to conduct crucial pre-procedure checks, compounded by confusing medical records and absent consultant respiratory cover.

Concerns summary A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to follow existing guidelines for specialist interpretation and requiring a review of current protocols.

Concerns summary Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.

Concerns summary Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. Additionally, prescribed discharge medication was not provided.

Concerns summary Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.

Concerns summary The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.

Concerns summary The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.

Concerns summary A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.

Concerns summary Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of Abortion Act amendments. Foeticide should be considered before induction at this stage.

Concerns summary Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate treatment and a lack of necessary barrier nursing, highlighting failures in inter-hospital documentation.

Concerns summary A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.

Concerns summary Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.

Concerns summary Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, despite clear indications of below-normal growth, no referral for further specialist opinion or scan was made.

Concerns summary The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways even when experienced clinicians assess rare conditions.

Concerns summary The concerns text provided for this report was incomplete, preventing a summary of specific issues.

Concerns summary Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, impacted patient care and readiness for surgery.