Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a lack of clear medical cause of death.

Concerns summary A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.

Concerns summary Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.

Concerns summary Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed patient care.

Concerns summary Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.

Concerns summary Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.

Concerns summary Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.

Concerns summary Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent serious fall.

Concerns summary Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating condition.

Concerns summary Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.

Concerns summary Critical failures in communicating care plans and changes in writing, along with a lack of clear avenues for challenging decisions or raising concerns for patients and families.

Concerns summary Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.

Concerns summary Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant demand.

Concerns summary Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

Concerns summary Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.

Concerns summary Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.

Concerns summary Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.

Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.

Concerns summary Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, and significant CT scan delays.

Concerns summary Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack of reviews, placing multiple patients at risk.

Concerns summary Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.

Concerns summary Simultaneous staff breaks led to insufficient ward cover and unsupervised patients, directly resulting in a fall; this unsafe staffing practice was still ongoing despite being criticised.

Concerns summary Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.

Concerns summary A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths due to delayed diagnosis and treatment.

Concerns summary Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.