Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.

Concerns summary A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.

Concerns summary The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.

Concerns summary The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.

Concerns summary Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.

Concerns summary Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.

Concerns summary Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked patient safety.

Concerns summary No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.

Concerns summary Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.

Concerns summary A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.

Concerns summary Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.

Concerns summary Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.

Concerns summary There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.

Concerns summary Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.

Concerns summary Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.

Concerns summary A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to significant mortality and morbidity risks.

Concerns summary Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.

Concerns summary Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.

Concerns summary Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.

Concerns summary Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.

Concerns summary There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with staff lacking understanding of police protocols and information requirements, leading to delayed high-risk classification.

Concerns summary The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.

Concerns summary There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.

Concerns summary Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, delaying crucial assessment and appropriate referral.

Concerns summary Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.