Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental health teams.

Concerns summary The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.

Concerns summary The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.

Concerns summary A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.

Concerns summary Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory factor to depression in peri-menopausal women.

Concerns summary Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment for his complex needs in a standard ward setting.

Concerns summary The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.

Concerns summary The DVT risk assessment was inadequate, failing to recognise significant risk factors like obesity, inactivity, and a known medication side effect for a patient with reduced mobility.

Concerns summary Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and abnormal vital signs. Unclear escalation procedures and inadequate staff training risk similar future incidents.

Concerns summary There was a complete failure in falls prevention, with inadequate multidisciplinary management and insufficient supervision for a confused, agitated patient. Wards were dangerously understaffed, failing to provide required enhanced care levels.

Concerns summary There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.

Concerns summary The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.

Concerns summary The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE guidelines and has been an unresolved issue since at least 2018.

Concerns summary Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.

Concerns summary Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.

Concerns summary Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack of clarity and potential gaps in ensuring fetal well-being.

Concerns summary The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and the patient being discharged to unsafe living conditions.

Concerns summary A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have prolonged life.

Concerns summary The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered an inpatient fall due to inadequate supervision and care for his confused state.

Concerns summary Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, which led to unaddressed severe injuries and no post-death investigation.

Concerns summary A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.

Concerns summary Systemic failures included misinterpretation of CT scans, staff unawareness of patient spinal conditions and equipment features, incomplete fall assessments, and unrecorded adverse reactions to procedures.

Concerns summary Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate this as a serious incident.

Concerns summary Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.

Concerns summary Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.