Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.

Concerns summary Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.

Concerns summary Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.

Concerns summary Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 days.

Concerns summary A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.

Concerns summary The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.

Concerns summary Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, posing a risk of future deaths.

Concerns summary Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.

Concerns summary Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines for the LISA procedure and newborn cardiac arrest causes.

Concerns summary Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of regional mutual aid.

Concerns summary A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.

Concerns summary Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.

Concerns summary The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.

Concerns summary Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.

Concerns summary During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.

Concerns summary Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.

Concerns summary Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG traces.

Concerns summary The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of future deaths.

Concerns summary The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning Disability Liaison Nurse, leading to poor care.

Concerns summary A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.

Concerns summary Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical response to critical patient conditions.

Concerns summary Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. This systemic issue affects safe patient care and transfers.

Concerns summary Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose a risk of future deaths.

Concerns summary Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient waits for reviews are caused by staffing shortages and insufficient funding.

Concerns summary A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.