Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.

Concerns summary Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.

Concerns summary The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and the patient being discharged to unsafe living conditions.

Concerns summary A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.

Concerns summary Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.

Concerns summary Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.

Concerns summary Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, which lack interoperability and require manual input.

Concerns summary Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.

Concerns summary The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.

Concerns summary Concerns include inadequate patient consent processes, with explanations given minutes before major surgery, and nursing staff failing to consistently escalate monitoring or seek clinical review after non-reassuring vital signs.

Concerns summary Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.

Concerns summary Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.

Concerns summary Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.

Concerns summary A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.

Concerns summary Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.

Concerns summary A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.

Concerns summary There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a Tissue Viability Nurse. This was compounded by a lack of clear guidelines for TVN referrals and involvement in prevention plans.

Concerns summary Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.

Concerns summary There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.

Concerns summary An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.

Concerns summary Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.

Concerns summary A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.

Concerns summary The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.

Concerns summary The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.

Concerns summary Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.