Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.

Concerns summary The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.

Concerns summary The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.

Concerns summary The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.

Concerns summary Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.

Concerns summary Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.

Concerns summary Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.

Concerns summary An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.

Concerns summary Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.

Concerns summary A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.

Concerns summary A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.

Concerns summary Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.

Concerns summary There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.

Concerns summary The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.

Concerns summary Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.

Concerns summary Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.

Concerns summary The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.

Concerns summary Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent deterioration.

Concerns summary Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.

Concerns summary Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked training to access historical imaging.

Concerns summary Concerns text is severely truncated and does not provide sufficient information to identify specific safety issues or systemic failures.

Concerns summary Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.

Concerns summary Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

Concerns summary Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.

Concerns summary Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.