Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The family also faced barriers in sharing critical information with professionals.

Concerns summary Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation may be critically needed.

Concerns summary The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.

Concerns summary The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating a critical delay in adopting patient safety improvements post-Root Cause Analysis.

Concerns summary An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed for nearly seven weeks due to cancellation and rescheduling.

Concerns summary The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The hospital also lacked a protocol for vulnerable patients who self-discharge, particularly regarding follow-up and essential medication.

Concerns summary The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.

Concerns summary There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, were seen and re-engaged, leading to discharge without adequate follow-up after an initial appointment failure.

Concerns summary Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning and escalating patient deterioration to consultants.

Concerns summary There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, with the crisis team unable to fill this gap.

Concerns summary Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not being used despite immobility and involuntary movements.

Concerns summary The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. Additionally, communication with the supportive family regarding the patient's elevated risk was insufficient.

Concerns summary Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.

Concerns summary Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.

Concerns summary A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.

Concerns summary The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.

Concerns summary Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a lack of appropriate management to ensure nurses adhered to observation guidelines.

Concerns summary The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an Enhanced Care/Observation Standard Operating Procedure remain unclear.

Concerns summary Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of support upon discharge.

Concerns summary The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.

Concerns summary The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.

Concerns summary The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is critically needed, as current separation of care increases risk.

Concerns summary Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear prohibition policy.

Concerns summary The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.

Concerns summary An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, despite the known risks.