Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.

Concerns summary Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, potentially delaying diagnosis and treatment for patients with breast implants.

Concerns summary A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.

Concerns summary The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical power loss due to inadequate training. The ward lacked isolated power supply, and there was no system to detect mains power failure.

Concerns summary A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.

Concerns summary The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.

Concerns summary The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff during a theatre procedure.

Concerns summary The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.

Concerns summary The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.

Concerns summary Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.

Concerns summary Multiple systemic failures included inadequate falls risk assessment, missing neurological charts, poor communication between medical and nursing staff, immediate shredding of handover sheets, and insufficient incident reporting.

Concerns summary Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of missing a fracture outweighs radiation exposure risk for elderly patients.

Concerns summary There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.

Concerns summary The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve systems for acting on discharge summaries regarding patient medication.

Concerns summary A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.

Concerns summary A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.

Concerns summary Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.

Concerns summary Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.

Concerns summary Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.

Concerns summary Failures included an unreviewed discharge despite deteriorating patient condition, poor discharge coordination, inadequate record-keeping, lack of protocol for inpatient emergency calls, and a critical absence of inpatient clinical psychology services.

Concerns summary Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.

Concerns summary Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.

Concerns summary Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.

Concerns summary The provided concerns text is incomplete, making it impossible to identify specific safety issues or systemic failures regarding Marie Rollason's care.

Concerns summary Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records were also unavailable.