Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic failures.

Concerns summary Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.

Concerns summary Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This service gap may exist nationally.

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 significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.

Concerns summary A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses and treatment delays.

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 A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.

Concerns summary The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.

Concerns summary There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.

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 Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.

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 Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial clinical information.

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 Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.

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 Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific training in identifying such bleeding.

Concerns summary The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.

Concerns summary Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient to attend in person for benefits.

Concerns summary Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.

Concerns summary Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting observations lacked professional regulatory oversight.

Concerns summary The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.

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.