Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.

Concerns summary The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially with a filter. A more robust docking mechanism is needed to prevent inadvertent disconnections.

Concerns summary Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.

Concerns summary A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.

Concerns summary Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.

Concerns summary A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy led to chaotic team malfunction during a critical emergency.

Concerns summary Inadequate staffing, poor call bell response times, and a systemic failure to complete falls risk assessments for vulnerable patients compromise safety across hospital wards.

Concerns summary Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice for managing patient resistance to turning.

Concerns summary Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, and the manufacturer has not provided a solution.

Concerns summary Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating health.

Concerns summary Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and incomplete information. There is no specific NICE guidance for elderly femur fracture management.

Concerns summary The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated or understood by all relevant staff.

Concerns summary Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future fatalities.

Concerns summary The provided text is a generic statement of concern, without specifying the particular matters that led to the risk of future deaths.

Concerns summary The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.

Concerns summary CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with multiple alarms.

Concerns summary Neurological observations prescribed after a head injury were discontinued without explanation or documentation, preventing proper monitoring of the patient's condition.

Concerns summary An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.

Concerns summary The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.

Concerns summary The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.

Concerns summary Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.

Concerns summary Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by capacity, not clinical need.

Concerns summary Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate systemic failures in patient care and information management.

Concerns summary Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols were not followed due to miscommunication and poor record-keeping.

Concerns summary A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the care coordinator and a recent suicide attempt.