Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside inadequate monitoring and care continuity, led to missed patient deterioration.

Concerns summary The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring food and fluid intake were inadequately followed during her inpatient care.

Concerns summary An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating sepsis protocol, inadequate monitoring, and delayed senior review, which significantly contributed to the patient's deterioration.

Concerns summary Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading to insufficient patient monitoring and significant ambulance handover delays.

Concerns summary Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust morbidity review after the patient's death.

Concerns summary Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College guidance for returning ED patients and investigating neurological findings like subarachnoid haemorrhage, with learning not effectively embedded.

Concerns summary Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks and delayed diagnosis of severe injuries.

Concerns summary Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's hydration policy, leading to patient dehydration without clear accountability.

Concerns summary Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses managing patients without this critical safety knowledge.

Concerns summary The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis to at-risk patients in the community could prevent future delayed recognition and response.

Concerns summary Critical communication breakdowns during hospital discharge led to a failure in securing a pressure-relieving bed and a lack of clear instructions for daily skin integrity checks by district nurses and carers, exacerbated by social services missing key risk information.

Concerns summary Senior nursing staff failed to implement comprehensive care plans, including capacity assessments for refusing observations, and critically, did not recognize or urgently respond to a patient's acutely deteriorating clinical condition.

Concerns summary The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns about inadequate pre-treatment assessment and the need for mandatory First Aid training for chiropractors.

Concerns summary Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and Hydration Committee suffers from inconsistent support and attendance.

Concerns summary Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, non-emergency method to alert the paediatric team.

Concerns summary The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to monitor whether care plans were being met, despite clear signs of refusal for essential care.

Concerns summary External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading to potential delivery of conflicting care and an unsafe environment.

Concerns summary The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.

Concerns summary The lack of a 24/7 thrombectomy service in Cornwall creates a "postcode lottery" for stroke patients, compounded by the absence of a service level agreement with the nearest specialist unit.

Concerns summary There was a four-day delay in conducting a crucial CT head scan after an elderly patient's fall and suspected head injury. Additionally, the patient was inappropriately prescribed an anticoagulant before the scan.

Concerns summary Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.

Concerns summary Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient deterioration and re-admissions, exacerbating hospital pressures.

Concerns summary There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.

Concerns summary Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack of awareness for neutropenic sepsis guidance also led to missed red flags and delayed critical treatment.

Concerns summary A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures among clinical staff and poor record-keeping led to serious patient harm.