Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.

Concerns summary Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.

Concerns summary A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.

Concerns summary Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.

Concerns summary Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.

Concerns summary A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.

Concerns summary There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.

Concerns summary Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.

Concerns summary A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to significant mortality and morbidity risks.

Concerns summary Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.

Concerns summary There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.

Concerns summary Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, delaying crucial assessment and appropriate referral.

Concerns summary Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants of these cases.

Concerns summary The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.

Concerns summary Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.

Concerns summary Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, staff training, and the methods for recording and retrieving critical data.

Concerns summary A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.

Concerns summary Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record entries, failing to provide timely, vital information for subsequent shifts.

Concerns summary Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.

Concerns summary Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds risk future preventable deaths.

Concerns summary The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.

Concerns summary Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.

Concerns summary A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a trauma series CT scan or c-spine imaging.

Concerns summary The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of a learning disability liaison role.

Concerns summary A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.