Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.

Concerns summary A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.

Concerns summary There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant attendance.

Concerns summary The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from recognising seriously ill children despite low scores.

Concerns summary A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.

Concerns summary Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.

Concerns summary Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of aspiration.

Concerns summary The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.

Concerns summary The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, without specifying the issues or failures.

Concerns summary Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.

Concerns summary NHS Pathways' toddler/child assessment tools are failing to identify very sick children, a persistent and unaddressed risk despite prior investigations.

Concerns summary Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.

Concerns summary The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.

Concerns summary There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed Amiodarone, particularly concerning liver, thyroid, and respiratory function during the initial treatment period.

Concerns summary The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying this as a risk.

Concerns summary Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.

Concerns summary Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.

Concerns summary Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health and education systems.

Concerns summary Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits and inconsistent glucose testing, for mental health patients. This indicates a systemic failure to implement crucial safety recommendations and ensure appropriate medical oversight.

Concerns summary A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.

Concerns summary The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.

Concerns summary A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient safety.

Concerns summary There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.

Concerns summary Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.

Concerns summary A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.