Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation quality and specialist nurses failing to act on patient concerns.

Concerns summary A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect care being provided by district nurses.

Concerns summary Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating non-attendance, allowing newly referred patients to slip through the system.

Concerns summary Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with inadequate training leading to failures in best interests decision-making and patient/family involvement.

Concerns summary A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.

Concerns summary The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall risks and unclear roles regarding patient assistance.

Concerns summary Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk of critical information loss.

Concerns summary A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false observation records due to a culture of impunity, and critical monitoring protocols after rapid tranquilisation were not followed.

Concerns summary A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without appropriate care.

Concerns summary Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also no escalation process for medication refusal, exacerbated by a national bed shortage.

Concerns summary National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls and contracting nosocomial infections.

Concerns summary A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of falls and fatal injuries, compromising staff's ability to provide safety.

Concerns summary Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.

Concerns summary A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.

Concerns summary A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a critical antibiotic was not confirmed.

Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.

Concerns summary A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.

Concerns summary The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.

Concerns summary Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.

Concerns summary Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered an urgent cardiology referral.

Concerns summary Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff training.

Concerns summary Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.

Concerns summary Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack of standardized care.

Concerns summary Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.

Concerns summary Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.