Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.

Concerns summary Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.

Concerns summary Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.

Concerns summary The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for the procedure or alternative feeding methods.

Concerns summary There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.

Concerns summary Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Concerns summary A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.

Concerns summary Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.

Concerns summary A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.

Concerns summary Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.

Concerns summary There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.

Concerns summary The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol liaison nurse post-discharge.

Concerns summary A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.

Concerns summary A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition regarding the absconding risk when allowing a detained patient leave.

Concerns summary A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use of early warning systems.

Concerns summary Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.

Concerns summary Hospital discharge procedures are unacceptably slow, taking weeks rather than days, highlighting a need for a more efficient local protocol between the Hospital Trust and CCG.

Concerns summary Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.

Concerns summary The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.

Concerns summary No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.

Concerns summary Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.

Concerns summary Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.

Concerns summary There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.

Concerns summary Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.

Concerns summary Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.