Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS score were identified.

Concerns summary Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.

Concerns summary Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Concerns summary Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.

Concerns summary A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.

Concerns summary The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Concerns summary PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.

Concerns summary Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.

Concerns summary Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.

Concerns summary Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

Concerns summary Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.

Concerns summary A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.

Concerns summary Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also inadequate pain management, poor continuity of care, and communication failures.

Concerns summary A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was needed. No serious incident investigation followed his death.

Concerns summary A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was responsible for the patient's ongoing care.

Concerns summary Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor ventilation. Police lacked sufficient powers to intervene effectively in squatted commercial premises.

Concerns summary Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.

Concerns summary Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.

Concerns summary Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.

Concerns summary The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly highlighted. The MHRA failed to escalate this known hazard to other hospital trusts.

Concerns summary Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's death.

Concerns summary UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, thereby increasing patient risk.

Concerns summary The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked essential diagnostic facilities.

Concerns summary There was a failure to disseminate trust policy and NPSA guidance, along with weak training systems. Staff training currency was not checked, and knowledge of trained staff numbers for critical procedures was lacking.

Concerns summary Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.