Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.

Concerns summary Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.

Concerns summary The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and assisted technology for patient falls prevention are significantly delayed.

Concerns summary The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic steps.

Concerns summary Vulnerable young people face dangerously long waiting lists (over a year) for psychological therapy and specialist services like the Gender Identity Clinic, leaving a critical gap in support between urgent and non-urgent mental health interventions.

Concerns summary Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor clinical documentation compromising patient safety.

Concerns summary Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor record-keeping and communication, an incomplete incident action plan, and no regulatory referral for staff failings.

Concerns summary A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.

Concerns summary A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.

Concerns summary Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.

Concerns summary A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to identify a critically ill patient.

Concerns summary Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health Professional, increasing risk of self-harm or suicide.

Concerns summary Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.

Concerns summary The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.

Concerns summary Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.

Concerns summary A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.

Concerns summary Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.

Concerns summary Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to provide adequate care, particularly for vulnerable patients.

Concerns summary There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking patient safety where GPs prescribe at hospital request.

Concerns summary Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home hindered proper assessment of changing patient conditions.

Concerns summary Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of clinical discussions pose significant risks to patient care.

Concerns summary Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and a lack of follow-up systems for referrals hindered effective patient care and risk identification.

Concerns summary CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting systemic failures in equipment design and training compliance.

Concerns summary The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.

Concerns summary A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.