Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.

Concerns summary A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.

Concerns summary Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.

Concerns summary Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.

Concerns summary Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.

Concerns summary Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, overstretching Home Treatment Teams.

Concerns summary Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.

Concerns summary Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.

Concerns summary Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.

Concerns summary Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, and unread clinical notes, compounded by a lack of statutory consent process for informal patients.

Concerns summary Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.

Concerns summary A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling to meet the patient's requirements.

Concerns summary Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a lack of national guidelines for this procedure.

Concerns summary A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and potentially delayed emergency treatment.

Concerns summary The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking premature births.

Concerns summary An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.

Concerns summary Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.

Concerns summary Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled with ineffective EPR alerts, increased the risk of avoidable death.

Concerns summary A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.

Concerns summary Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.

Concerns summary A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.

Concerns summary "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.

Concerns summary The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy to guide responses.

Concerns summary Midwives' advice encourages unsafe co-sleeping practices for fatigued mothers, risking infant death. Furthermore, critical patient information was frequently omitted from standard Trust documentation.

Concerns summary Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when the unit is full and caring for very sick babies.