Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary There was a critical failure to assign a single person overall responsibility for the patient, with no new Care Co-Ordinator appointed. A recommendation for all patients to have a lead professional was marked complete but not implemented.

Concerns summary Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.

Concerns summary County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.

Concerns summary There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.

Concerns summary Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay in providing thromboprophylaxis.

Concerns summary Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

Concerns summary Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.

Concerns summary Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.

Concerns summary Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention procedures were insufficient.

Concerns summary Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks at handover.

Concerns summary Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm prevention.

Concerns summary Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due to an apparent lack of awareness regarding their complex needs.

Concerns summary Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.

Concerns summary Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due to high workload, and underutilised computer systems also raised concerns.

Concerns summary The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a single, departed manager, with no audit or review since, despite missing documentation.

Concerns summary A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and conducted subjective risk assessments, further compounded by transitioning services and possible masking of symptoms.

Concerns summary There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.

Concerns summary There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.

Concerns summary Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.

Concerns summary Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.

Concerns summary Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely senior clinician contact were identified concerns.

Concerns summary Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and inadequate consideration of previous medical records before discharge.

Concerns summary A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.

Concerns summary Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.