Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health and education systems.

Concerns summary Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.

Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.

Concerns summary The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.

Concerns summary A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.

Concerns summary Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits and inconsistent glucose testing, for mental health patients. This indicates a systemic failure to implement crucial safety recommendations and ensure appropriate medical oversight.

Concerns summary A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.

Concerns summary Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.

Concerns summary Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke as an immediate emergency, risking critical treatment windows.

Concerns summary There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.

Concerns summary The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.

Concerns summary A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient safety.

Concerns summary A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.

Concerns summary Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.

Concerns summary There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.

Concerns summary The provided text is incomplete and does not detail any specific concerns or systemic failures that could lead to future deaths.

Concerns summary Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.

Concerns summary Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.

Concerns summary The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.

Concerns summary A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.

Concerns summary No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental health information was disregarded in their physical care.

Concerns summary The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.

Concerns summary Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.

Concerns summary Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her injury.

Concerns summary Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.