Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.

Concerns summary Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and concerns over 'Hospital at Night' co-ordinators' qualifications for medical prioritisation.

Concerns summary A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.

Concerns summary Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The hospital also failed to contact family/friends despite consent, and the community team did not proactively seek discharge information.

Concerns summary The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.

Concerns summary The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.

Concerns summary The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to implement cast care plans, monitor for infection, or train staff.

Concerns summary Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.

Concerns summary The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.

Concerns summary There was a critical failure to assign a single person overall responsibility for the patient, with no new Care Co-Ordinator appointed. A recommendation for all patients to have a lead professional was marked complete but not implemented.

Concerns summary The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.

Concerns summary A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.

Concerns summary Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.

Concerns summary County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.

Concerns summary There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.

Concerns summary Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay in providing thromboprophylaxis.

Concerns summary Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

Concerns summary There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.

Concerns summary Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect patient scores and policy non-adherence.

Concerns summary Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.

Concerns summary A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.

Concerns summary Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication protocols between staff and ambulance services were inconsistent.

Concerns summary Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear roles, poor observation recording, and deficient handover systems.

Concerns summary Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.

Concerns summary Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.