Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.

Concerns summary The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.

Concerns summary Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.

Concerns summary A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.

Concerns summary The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of a critical abdominal issue.

Concerns summary The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating their conditions.

Concerns summary A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.

Concerns summary Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.

Concerns summary Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.

Concerns summary Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a significant delay in diagnosing a critical condition.

Concerns summary The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.

Concerns summary Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, inadequate interpretation of radiology findings, and improper use of early warning scores for sepsis.

Concerns summary The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.

Concerns summary Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.

Concerns summary Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and administrative errors, caused significant delays in secondary care access.

Concerns summary There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for medical interventions was also absent.

Concerns summary Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.

Concerns summary There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.

Concerns summary Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.

Concerns summary There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including a failure to escalate the transfer decision to a consultant.

Concerns summary There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are present, leading to inconsistent clinical judgments and limited practitioner experience.

Concerns summary The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.

Concerns summary Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.

Concerns summary Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.

Concerns summary Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.