Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.

Concerns summary There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.

Concerns summary There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.

Concerns summary Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.

Concerns summary Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped areas.

Concerns summary Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.

Concerns summary The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.

Concerns summary No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.

Concerns summary Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.

Concerns summary Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.

Concerns summary Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 days.

Concerns summary A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.

Concerns summary The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.

Concerns summary Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, posing a risk of future deaths.

Concerns summary Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.

Concerns summary Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines for the LISA procedure and newborn cardiac arrest causes.

Concerns summary A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.

Concerns summary Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of regional mutual aid.

Concerns summary A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not a mental health service.

Concerns summary A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.

Concerns summary Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.

Concerns summary The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.

Concerns summary Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.

Concerns summary During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.

Concerns summary Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.