Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or IV infusions, in relation to falls risk.

Concerns summary Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.

Concerns summary A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.

Concerns summary The falls risk assessment was completed inaccurately and not reassessed despite family warnings about compromised mobility. Furthermore, the Trust's internal investigation failed to identify these critical failures.

Concerns summary Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus stenting and associated perforation risks.

Concerns summary Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about wider patient safety.

Concerns summary Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, missing opportunities for earlier specialist assessment.

Concerns summary Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.

Concerns summary Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen testing for under 5s, creates diagnostic delays.

Concerns summary The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.

Concerns summary Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.

Concerns summary A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel perforation risk for diverticular disease patients.

Concerns summary An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.

Concerns summary National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing their risk of harm.

Concerns summary Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also delayed crucial organizational learning.

Concerns summary Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a patient with Addison's disease after trauma. Trust guidelines and documentation lacked crucial prompts for adrenal insufficiency.

Concerns summary Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received no medical review for four days, indicating a severe failure in monitoring and timely clinical intervention.

Concerns summary Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical priority. Delays in incident reporting and family communication were also noted.

Concerns summary The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.

Concerns summary The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge were significantly delayed.

Concerns summary Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.

Concerns summary The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, including non-closing doors to high-risk areas, were inadequately mitigated, and the internal investigation was unreliable.

Concerns summary Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.

Concerns summary The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.

Concerns summary Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.