Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.

Concerns summary Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.

Concerns summary Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative checks lacked a standard question about recent vomiting, contributing to surgical risks.

Concerns summary A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.

Concerns summary Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.

Concerns summary Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.

Concerns summary Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.

Concerns summary Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.

Concerns summary The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.

Concerns summary The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.

Concerns summary Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.

Concerns summary The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.

Concerns summary Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with scanty hospital notes, created significant misunderstandings and risks.

Concerns summary An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.

Concerns summary The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.

Concerns summary Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.

Concerns summary Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.

Concerns summary A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.

Concerns summary A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.

Concerns summary A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.

Concerns summary Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.

Concerns summary Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.

Concerns summary Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.

Concerns summary Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.

Concerns summary Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.