Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient experienced a severe lack of nursing care, poor communication leading to unmanaged diabetes, and was left without vital intravenous fluids despite renal failure, with no adequate hospital investigation following.

Concerns summary Critical failures included missing records for patient rounding and neurological observations, and junior doctors failing to follow consultant instructions for pre-discharge assessments. Premature distribution of discharge paperwork also led to confusion.

Concerns summary The coroner identified a critical breakdown in communication as a key concern.

Concerns summary No specific concerns were detailed in the provided text for this report.

Concerns summary Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration of new symptoms leading to poor risk assessment. The clinical risk policy was unclear for non-in-person assessments.

Concerns summary A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a crucial electronic prescribing system with no clear implementation timeline.

Concerns summary Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates significant management difficulties.

Concerns summary Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other professionals despite poor patient rapport.

Concerns summary Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.

Concerns summary An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient placement.

Concerns summary Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a lack of patient examination prior to the procedure.

Concerns summary Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.

Concerns summary The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.

Concerns summary Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content and potential for ingestion, posing a significant safety risk.

Concerns summary A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is a delay in finalising and implementing updated national guidance for neonatal hypoglycaemia management.

Concerns summary Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.

Concerns summary Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.

Concerns summary Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.

Concerns summary Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.

Concerns summary An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.

Concerns summary The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.

Concerns summary A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, and drug accumulation in long-term therapy.

Concerns summary A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.

Concerns summary Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.