Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue leaves mothers and babies at continued risk.

Concerns summary Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.

Concerns summary Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.

Concerns summary Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID wards, a risk potentially unresolved in other trusts.

Concerns summary A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.

Concerns summary The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures for high-risk elderly patients.

Concerns summary Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits hindered comprehensive risk assessment and family involvement.

Concerns summary National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across trusts.

Concerns summary The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.

Concerns summary Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.

Concerns summary Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. This delay in addressing competence issues poses a risk to future patients.

Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.

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 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 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 Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was exacerbated by poor escalation of care when the primary consultant was unavailable.

Concerns summary Medical professionals lacked awareness of the dangerous bacteria *Capnocytophaga canimorsus* and its risks, coupled with insufficient public awareness for at-risk individuals to seek urgent care after pet bites.

Concerns summary Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.

Concerns summary The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, needs to be confirmed and any partial implementation justified.

Concerns summary Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.

Concerns summary Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to a lack of documentation pose ongoing risks.

Concerns summary Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).

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 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.