Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.

Concerns summary Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.

Concerns summary Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. Its hyperinfection syndrome presents with non-specific symptoms, risking severe progression.

Concerns summary A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a child with complex needs. Inconsistent understanding of protocols and the "red book" exacerbated these issues.

Concerns summary Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a less safe system.

Concerns summary Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent cases are inadequate, risking rapid patient deterioration.

Concerns summary The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.

Concerns summary NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for symptoms like green vomit.

Concerns summary Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.

Concerns summary There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Concerns summary Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.

Concerns summary The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.

Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Concerns summary The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.

Concerns summary The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.

Concerns summary A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.

Concerns summary Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may invalidate findings when mood is low.

Concerns summary Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.

Concerns summary A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer guidance on cardiac monitoring.

Concerns summary NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.

Concerns summary A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.

Concerns summary Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised patient care.

Concerns summary Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not seen by the discharging doctor due to systemic record-keeping failures and inadequate alert systems.

Concerns summary The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.

Concerns summary A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.