Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.

Concerns summary Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.

Concerns summary Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.

Concerns summary Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.

Concerns summary Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.

Concerns summary Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call delays due to the absence of an emergency protocol.

Concerns summary Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.

Concerns summary Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked training to access historical imaging.

Concerns summary Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.

Concerns summary Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.

Concerns summary Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent deterioration.

Concerns summary Concerns text is severely truncated and does not provide sufficient information to identify specific safety issues or systemic failures.

Concerns summary Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.

Concerns summary Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.

Concerns summary Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.

Concerns summary Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.

Concerns summary Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.

Concerns summary Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

Concerns summary Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.

Concerns summary Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.

Concerns summary Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to thrombolytic therapy and massive blood loss.

Concerns summary Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.

Concerns summary Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. Discharge notes were also incomplete and checklists unfulfilled.

Concerns summary Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due to increased workloads.

Concerns summary Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of Crisis Resolution Home Treatment Teams as a barrier to inpatient bed access.