Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.

Concerns summary An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate imaging or confirmation of its position, delaying critical haemothorax management.

Concerns summary Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.

Concerns summary Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.

Concerns summary Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.

Concerns summary Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.

Concerns summary Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.

Concerns summary A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.

Concerns summary A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in some hospitals.

Concerns summary Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.

Concerns summary Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.

Concerns summary Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.

Concerns summary The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.

Concerns summary Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.

Concerns summary Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.

Concerns summary Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and a failure to assess risks to other patients and staff. There were no agreed protocols or senior oversight.

Concerns summary There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.

Concerns summary A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.

Concerns summary Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.

Concerns summary Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.

Concerns summary A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.

Concerns summary A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.

Concerns summary The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.

Concerns summary The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff during a theatre procedure.

Concerns summary The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.