Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.

Concerns summary Concerns focus on easily accessible button batteries in products not classified as toys, lack of national awareness regarding ingestion risks, and medical professionals needing better guidance for such incidents.

Concerns summary There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.

Concerns summary Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient lives at risk due to lack of specialist advice.

Concerns summary The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.

Concerns summary The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.

Concerns summary There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.

Concerns summary Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.

Concerns summary The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.

Concerns summary Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist procedures. Additionally, poor communication, failure to assess mental capacity, and obtain consent for treatment were identified.

Concerns summary Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system enhancements.

Concerns summary New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.

Concerns summary There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.

Concerns summary Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.

Concerns summary Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.

Concerns summary Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.

Concerns summary Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.

Concerns summary The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.

Concerns summary A critical lack of detailed national guidance for antepartum CTG assessment, interpretation, and intervention, leading to inconsistent and potentially unsafe management of high-risk pregnancies.

Concerns summary Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.

Concerns summary Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.

Concerns summary A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.

Concerns summary The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.

Concerns summary Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.

Concerns summary Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.