Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.

Concerns summary Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.

Concerns summary Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and poor record-keeping by senior staff.

Concerns summary Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.

Concerns summary Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.

Concerns summary The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.

Concerns summary The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no tracking mechanism for unprogressed cases.

Concerns summary The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.

Concerns summary Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.

Concerns summary Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health teams, leading to a dangerous gap in care.

Concerns summary There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.

Concerns summary A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.

Concerns summary An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail assessment, highlighting a lack of national guidelines for falls prevention in emergency departments.

Concerns summary There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.

Concerns summary The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care and risk planning.

Concerns summary There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.

Concerns summary Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.

Concerns summary A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health bed waits were also exacerbated by fragmented commissioning.

Concerns summary The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation delays and unapparent post-death amendments, compromising their integrity.

Concerns summary Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred policies effectively.

Concerns summary Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed acute conditions.

Concerns summary Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs were also not integrated into long-term plans.

Concerns summary There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, especially regarding post-treatment and discharge care.

Concerns summary Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external reporting service, Medica, has not committed to implementing this essential practice, leaving patients at risk.