Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.

Concerns summary A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.

Concerns summary The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would be followed to prevent future deaths.

Concerns summary The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.

Concerns summary The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in obstetric care and leading to inappropriate medical treatment.

Concerns summary Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information sharing between health agencies and the removal of medically qualified staff in schools, hindered comprehensive care.

Concerns summary Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.

Concerns summary Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital information being overlooked due to convoluted dissemination methods and outdated guidance.

Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.

Concerns summary Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.

Concerns summary A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a child with complex needs. Inconsistent understanding of protocols and the "red book" exacerbated these issues.

Concerns summary The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.

Concerns summary There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Concerns summary Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.

Concerns summary A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.

Concerns summary A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.

Concerns summary Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.

Concerns summary A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.

Concerns summary There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.

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

Concerns summary Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.

Concerns summary A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.

Concerns summary Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.

Concerns summary There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.

Concerns summary Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health unit staff untrained in IV fluid administration were significant issues.