Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of local beds and distant, unappealing out-of-area options, exacerbated by age-segregated units.

Concerns summary Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing suicide risk.

Concerns summary The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for patients.

Concerns summary Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.

Concerns summary A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.

Concerns summary Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.

Concerns summary Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.

Concerns summary The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention issues.

Concerns summary There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk to patient safety.

Concerns summary Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm to others.

Concerns summary Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols across trust sites created inconsistent care standards.

Concerns summary Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.

Concerns summary Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT reviews.

Concerns summary A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.

Concerns summary Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.

Concerns summary Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.

Concerns summary A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall evidence.

Concerns summary Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by an unavailable ICU outreach team and poor fluid chart completion.

Concerns summary Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.

Concerns summary An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.

Concerns summary Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.

Concerns summary Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, created unsafe care practices.

Concerns summary A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.

Concerns summary Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.

Concerns summary The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.