Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to a patient's concerns being overlooked before an inappropriate discharge.

Concerns summary Extended surgery wait times due to COVID backlogs and severe ambulance availability issues led to significant delays in critical care, causing distress and impacting patient outcomes.

Concerns summary Prolonged waits in the Emergency Department due to bed shortages and delays in essential surgery due to theatre capacity severely impacted the patient's physiological reserves and overall outcome.

Concerns summary Critical failures included a chaotic cardiac arrest response, non-escalation of elevated blood pressure, lack of VTE risk assessment, and unreviewed chest pain. Misinformation regarding a DNACPR was also not promptly admitted.

Concerns summary Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with epistaxis or facial fractures, potentially missing continued bleeding.

Concerns summary A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral haemorrhage.

Concerns summary Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs lacking clear guidance on escalating concerns.

Concerns summary There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.

Concerns summary Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely recognition and treatment.

Concerns summary NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other naturally occurring conditions affecting blood clotting, leading to missed diagnostic opportunities.

Concerns summary Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of death and confusion regarding DNAR status.

Concerns summary Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information sharing and holistic patient views.

Concerns summary Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, hindering timely and effective care.

Concerns summary The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior staff initially failed to recognise this error. This suggests a significant lack of learning and potential flaws in policy understanding or the policy itself.

Concerns summary Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be un-followed. The failure to escalate concerns was unclear.

Concerns summary Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. This impacts patient outcomes and mortality.

Concerns summary Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist nurse service's role was also poorly understood by community healthcare providers.

Concerns summary There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.

Concerns summary The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Concerns summary The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.

Concerns summary The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a serious incident.

Concerns summary Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care training.

Concerns summary Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring patients under section, including required documentation.

Concerns summary A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.

Concerns On 1 stApril 2021 this Court commenced an investigation into the death of Elizabeth Margaret Mills age 71 years. The investigation concluded at the end of the inquest held on the 12 th November 2021...