Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, failed inter-team referral, and a prolonged lack of patient contact.

Concerns summary No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.

Concerns summary The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts disabled toilet design guidance.

Concerns summary Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS score were identified.

Concerns summary Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.

Concerns summary Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Concerns summary Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.

Concerns summary Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.

Concerns summary A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.

Concerns summary The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.

Concerns summary The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Concerns summary PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.

Concerns summary Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.

Concerns summary Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.

Concerns summary High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.

Concerns summary The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.

Concerns summary Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

Concerns summary Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.

Concerns summary Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.

Concerns summary Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per NICE guidelines.

Concerns summary A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.

Concerns summary A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.

Concerns summary Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also inadequate pain management, poor continuity of care, and communication failures.

Concerns summary A patient with a long mental health history was discharged without a formal handover or recorded reason, despite the community team believing ongoing support was needed. No serious incident investigation followed his death.

Concerns summary A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was responsible for the patient's ongoing care.