Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for patients.

Concerns summary Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.

Concerns summary Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and inadequate consideration of previous medical records before discharge.

Concerns summary Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.

Concerns summary The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.

Concerns summary A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.

Concerns summary The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an uninvolved nurse practitioner, insufficient safety netting, and failure to commence heparin despite a DVT/PE differential posed significant risks.

Concerns summary Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.

Concerns summary Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.

Concerns summary Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for national guidelines to ensure consistent, timely treatment.

Concerns summary Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.

Concerns summary The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The family also faced barriers in sharing critical information with professionals.

Concerns summary Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation may be critically needed.

Concerns summary The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.

Concerns summary The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.

Concerns summary The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating a critical delay in adopting patient safety improvements post-Root Cause Analysis.

Concerns summary The Trust failed to adhere to both NICE guidelines and its own internal policies concerning cancer screening, referrals, diagnosis, and treatment.

Concerns summary An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed for nearly seven weeks due to cancellation and rescheduling.

Concerns summary Social Services and housing providers failed to proactively assess fire risks, make referrals to fire services, or install automatic water suppression systems and appropriate alarms for high-risk individuals.

Concerns summary The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.

Concerns summary The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.

Concerns summary The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The hospital also lacked a protocol for vulnerable patients who self-discharge, particularly regarding follow-up and essential medication.

Concerns summary The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.