Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine fracture.

Concerns summary A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.

Concerns summary The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.

Concerns summary Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from unprogressed requests and incorrect referral classifications.

Concerns summary Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a lack of cover during a consultant's annual leave, putting patients at risk.

Concerns summary There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis situations, highlighting a need for better training in emergency management.

Concerns summary A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising concerns about monitoring during transit.

Concerns summary Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication with the family about an initial fall.

Concerns summary Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert clinicians to new results, hindering diagnosis before discharge.

Concerns summary Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to informal versus sectioned patients, despite similar risks.

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

Concerns summary Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.

Concerns summary Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.

Concerns summary Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.

Concerns summary Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.

Concerns summary Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.

Concerns summary The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.

Concerns summary An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.

Concerns summary A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.

Concerns summary Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for support were not ensured post-discharge.

Concerns summary Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to the patient's death.

Concerns summary The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management and potential hospitalisation.

Concerns summary A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.

Concerns summary There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation lacking detail on clinical decision-making.