Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading to misinterpretation of needs.

Concerns summary Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care coordinator, hindering comprehensive mental health care.

Concerns summary It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.

Concerns summary Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.

Concerns summary Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.

Concerns summary Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.

Concerns summary The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.

Concerns summary There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.

Concerns summary Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.

Concerns summary There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental health teams.

Concerns summary The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.

Concerns summary The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.

Concerns summary A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.

Concerns summary Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment for his complex needs in a standard ward setting.

Concerns summary The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.

Concerns summary Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and abnormal vital signs. Unclear escalation procedures and inadequate staff training risk similar future incidents.

Concerns summary There was a complete failure in falls prevention, with inadequate multidisciplinary management and insufficient supervision for a confused, agitated patient. Wards were dangerously understaffed, failing to provide required enhanced care levels.

Concerns summary The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE guidelines and has been an unresolved issue since at least 2018.

Concerns summary Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.

Concerns summary Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack of clarity and potential gaps in ensuring fetal well-being.

Concerns summary A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have prolonged life.

Concerns summary The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered an inpatient fall due to inadequate supervision and care for his confused state.

Concerns summary Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, which led to unaddressed severe injuries and no post-death investigation.

Concerns summary Systemic failures included misinterpretation of CT scans, staff unawareness of patient spinal conditions and equipment features, incomplete fall assessments, and unrecorded adverse reactions to procedures.

Concerns summary Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate this as a serious incident.