Hospital Death (Clinical Procedures and medical management) related deaths

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.

Concerns summary The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.

Concerns summary There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.

Concerns summary There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.

Concerns summary The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.

Concerns summary NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.

Concerns summary Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.

Concerns summary There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack of specific guidance for managing infection risks associated with a retained deceased foetus following feticide.

Concerns summary The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's specific concerns regarding systemic failures or risks.

Concerns summary Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.

Concerns summary The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.

Concerns summary A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.

Concerns summary Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.

Concerns summary Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.

Concerns summary Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.

Concerns summary The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.

Concerns summary The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.

Concerns summary The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.

Concerns summary Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.

Concerns summary The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's denial of suicidal intent. The Trust's investigation was inaccurate and inadequate.

Concerns summary Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.

Concerns summary The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.

Concerns summary An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.