Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.

Concerns summary The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.

Concerns summary Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.

Concerns summary E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of awareness among carers and the deceased.

Concerns summary The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.

Concerns summary A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in some hospitals.

Concerns summary Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.

Concerns summary Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.

Concerns summary Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.

Concerns summary The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.

Concerns summary Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.

Concerns summary Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's condition. These delays significantly reduced her chances of survival.

Concerns summary There was a significant lack of understanding among Trust staff regarding Deprivation of Liberty Safeguards (DOLS) applications, their "place-specific" nature, and their appropriate use in relation to Mental Health Act detentions. This risks negatively impacting other patients' care.

Concerns summary Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.

Concerns summary The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of decisions. Additionally, a necessary consultant-led out-of-hours rota for post-surgery patients was not yet implemented.

Concerns summary Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.

Concerns summary Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and a failure to assess risks to other patients and staff. There were no agreed protocols or senior oversight.

Concerns summary There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.

Concerns summary The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.

Concerns summary A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.

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

Concerns summary The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.

Concerns summary Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.

Concerns summary Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.

Concerns summary Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.