Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.

Concerns summary Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.

Concerns summary Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.

Concerns summary Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.

Concerns summary Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient safety.

Concerns summary Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance created significant safety risks.

Concerns summary Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.

Concerns summary The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal head injury.

Concerns summary Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up of haematology advice led to significant care delays.

Concerns summary The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.

Concerns summary Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis and treatment.

Concerns summary Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays in arranging post-discharge care packages.

Concerns summary Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.

Concerns summary Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing a nurse from challenging a dangerous prescription.

Concerns summary Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique from arterial lines further exacerbated errors.

Concerns summary Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, and absence of a clear prescription plan for staff.

Concerns summary Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.

Concerns summary There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.

Concerns summary Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation equipment in maternity.

Concerns summary The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.

Concerns summary Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.

Concerns summary Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve awareness and earlier diagnosis has not been implemented.

Concerns summary There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in delivery suites hinders contemporaneous observation recording.

Concerns summary Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to share Listeria isolates, hindering timely outbreak identification.

Concerns summary The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor assessment and critical treatment for walk-in patients.