Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays and inappropriate treatment.

Concerns summary A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital environment.

Concerns summary Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.

Concerns summary An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying treatment and highlighting a guidance gap.

Concerns summary The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team support during procedures.

Concerns summary Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.

Concerns summary The day surgery patient assessment system lacks explicit requirements to question or record details about patients' haematological family history, or adequately document negative responses to related personal history questions.

Concerns summary Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.

Concerns summary Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are not repositioned as required.

Concerns summary There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.

Concerns summary The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.

Concerns summary Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.

Concerns summary Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.

Concerns summary A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive essential training on reviewing full reports.

Concerns summary Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.

Concerns summary Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.

Concerns summary There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.

Concerns summary There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering patient care.

Concerns summary Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.

Concerns summary There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.

Concerns summary There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.

Concerns summary Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.

Concerns summary Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped areas.

Concerns summary Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.

Concerns summary The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.