Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.

Concerns summary The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Concerns summary The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.

Concerns summary The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a serious incident.

Concerns summary Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care training.

Concerns summary Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring patients under section, including required documentation.

Concerns summary A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent investigation into this incident was inadequate, lacked proper format, and was not disclosed.

Concerns summary A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.

Concerns On 1 stApril 2021 this Court commenced an investigation into the death of Elizabeth Margaret Mills age 71 years. The investigation concluded at the end of the inquest held on the 12 th November 2021...

Concerns summary Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to ensure x-rays are completed when overlooked by staff, risking missed diagnoses.

Concerns summary The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.

Concerns summary An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's Trust's lack of transparency, scene preservation, and proper investigation exacerbated the issues.

Concerns summary Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information sharing between multiple care agencies for a high-risk patient.

Concerns summary Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.

Concerns summary Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis and treatment.

Concerns summary A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.

Concerns summary There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.

Concerns summary Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.

Concerns summary The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.

Concerns summary The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.

Concerns summary Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.

Concerns summary While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary care.

Concerns summary National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.

Concerns summary A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.

Concerns summary Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.