Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.

Concerns summary Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration concerns.

Concerns summary Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. "Normal birth" language on checklists is also concerning.

Concerns summary There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.

Concerns summary Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.

Concerns summary Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate community support and clinical rationale.

Concerns summary Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted as "okay," indicating a lack of clear policies and training for observation management.

Concerns summary Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a significant risk to patient safety.

Concerns summary Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to compromised care.

Concerns summary There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.

Concerns summary Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention and parental awareness.

Concerns summary Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.

Concerns summary The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.

Concerns summary The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.

Concerns summary System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and critical patient observations were not recorded or conveyed to specialists.

Concerns summary "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.

Concerns summary Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.

Concerns summary GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.

Concerns summary Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.

Concerns summary Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.

Concerns summary The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.

Concerns summary Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical delay.

Concerns summary The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.

Concerns summary Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.

Concerns summary The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person plan in place.