Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness during subsequent assessments.

Concerns summary Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis and treatment.

Concerns summary Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic scans.

Concerns summary The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.

Concerns summary Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.

Concerns summary The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.

Concerns summary Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.

Concerns summary Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.

Concerns summary Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.

Concerns summary A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.

Concerns summary Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical diagnostic investigations.

Concerns summary Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for call handlers.

Concerns summary The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.

Concerns summary Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed opportunities for timely life-saving treatment.

Concerns On 23"' June 2016 an Investigation was commenced into the death of Dianne Jane MACRAE. The investigation concluded by way of inquest on 17"^ and IS'" May 2017. The medical cause of death was:- 1a)...

Concerns summary A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.

Concerns summary Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.

Concerns summary Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Concerns summary A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.

Concerns summary Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.

Concerns summary A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.

Concerns summary Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.

Concerns summary There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.

Concerns summary A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use of early warning systems.

Concerns summary Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the Hospital Trust and CCG.