Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. Signs of sepsis were missed, and no surgical opinion was sought post-discharge.

Concerns summary No specific concerns identified within the provided text, which details a critical condition and subsequent death following an expedited delivery due to abnormal CTG tracing.

Concerns summary Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.

Concerns summary Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.

Concerns summary Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.

Concerns summary Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family involvement, and breaches of the Enhanced Care Policy.

Concerns summary Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.

Concerns summary Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.

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 Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.

Concerns summary Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" alerts, and unclear protocols for disconnections.

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 persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are "inevitable," compounded by unchecked patient discharge decisions.

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 Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.

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 Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.

Concerns summary Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.

Concerns summary Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.

Concerns summary Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.