Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Critical delays occurred in arranging mental health appointments, with re-referrals being treated as new, resulting in dangerously long waiting lists and delayed access to care.

Concerns summary The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.

Concerns summary There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.

Concerns summary Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.

Concerns summary A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.

Concerns summary A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised the patient's health.

Concerns summary Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."

Concerns summary Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."

Concerns summary Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as critical concerns. A lack of defined protocols risked delayed treatment for patients needing urgent surgery.

Concerns summary Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses a significant risk to timely patient care.

Concerns summary Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information was not consistently recorded.

Concerns summary The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of facilities poses a high risk to babies' lives.

Concerns summary The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication and information handling within the service.

Concerns summary The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical staff also appeared ineffective.

Concerns summary Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.

Concerns summary Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.

Concerns summary The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings or marked safe paths from parking to the entrance.

Concerns summary A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.

Concerns summary Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by an incomplete internal investigation.

Concerns summary Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing urgent psychiatric appointments and follow-up after concerning incidents.

Concerns summary Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.

Concerns summary Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Concerns summary Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.

Concerns summary A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.