Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.

Concerns summary The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.

Concerns summary Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home and district nurses, inadequate record-keeping, and non-adherence to pressure relieving strategies.

Concerns summary Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.

Concerns summary The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines and GPs' knowledge of how to access them.

Concerns summary A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused significant delays.

Concerns summary There are serious and concerning delays in ambulances arriving at the scene of incidents, potentially compromising timely patient care.

Concerns summary Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading to a patient's INR increasing dangerously without intervention.

Concerns summary A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.

Concerns summary Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.

Concerns summary The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain his full physical history promptly, compounded by poor information sharing between trusts.

Concerns summary Nursing staff lacked the knowledge and experience to perform neurological observations and respond to serious injuries, leading to delayed medical attention, poor record-keeping, and an absence of falls prevention or care planning. The hospital lacked systems to address staff inexperience.

Concerns summary The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.

Concerns summary Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and insufficient information provided to ambulance services.

Concerns summary There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe patient discharge procedure from acute hospitals.

Concerns summary Critical gaps exist in mandatory and assessed training for CTG tracing interpretation for both student and practicing midwives, leading to proficiency issues upon hospital recruitment.

Concerns summary Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.

Concerns summary The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.

Concerns summary Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.

Concerns summary An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family about the fatal risks of missed medication and follow-up contact.

Concerns summary There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.

Concerns summary Midwives and junior obstetricians demonstrated a critical lack of skill in interpreting abnormal cardiotocograph (CTG) traces. This highlights a systemic failure in CTG training and a need for mandatory competency testing for intrapartum care.

Concerns summary Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.

Concerns summary A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.

Concerns summary There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.