Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.

Concerns summary Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.

Concerns summary Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.

Concerns summary Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.

Concerns summary Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" alerts, and unclear protocols for disconnections.

Concerns summary A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are "inevitable," compounded by unchecked patient discharge decisions.

Concerns summary Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.

Concerns summary Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.

Concerns summary Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.

Concerns summary Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.

Concerns summary Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.

Concerns summary Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic failures.

Concerns summary Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.

Concerns summary Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This service gap may exist nationally.

Concerns summary A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.

Concerns summary A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses and treatment delays.

Concerns summary A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.

Concerns summary The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.

Concerns summary There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.

Concerns summary Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.

Concerns summary Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial clinical information.

Concerns summary Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific training in identifying such bleeding.

Concerns summary The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.

Concerns summary Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient to attend in person for benefits.

Concerns summary Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting observations lacked professional regulatory oversight.