Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.

Concerns summary Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants of these cases.

Concerns summary A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal investigation findings. An essential transfer protocol also remained uncompleted, risking inappropriate discharges.

Concerns summary Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, despite previous assurances.

Concerns summary The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.

Concerns summary A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.

Concerns summary Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need to explore all options, leading to unconsulted and potentially inappropriate treatment decisions.

Concerns summary Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for anaemia management and iron infusion observation were not followed, compounded by unrecorded pharmacist-clinician discussions.

Concerns summary Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.

Concerns summary Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.

Concerns summary Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, staff training, and the methods for recording and retrieving critical data.

Concerns summary The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised improvements from previous PFD reports concerning transfer protocols.

Concerns summary A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.

Concerns summary Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record entries, failing to provide timely, vital information for subsequent shifts.

Concerns summary A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed diagnoses, and wasted time for complex cases.

Concerns summary Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.

Concerns summary Ambiguous medication packaging contributed to an error, which the MHRA failed to address. There's a need for enhanced guidance and training for nursing and pharmacy staff on thorough medication checks and documentation at all stages.

Concerns summary Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds risk future preventable deaths.

Concerns summary The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.

Concerns summary Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.

Concerns summary A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a trauma series CT scan or c-spine imaging.

Concerns summary Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.

Concerns summary GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.

Concerns summary GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.

Concerns summary The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of a learning disability liaison role.