Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Discharge letters lacked detail for GPs, KMPT failed to maintain post-discharge contact as per policy, and communication with patient families regarding discharge decisions was inadequate. Staff were also unaware of KMPT's discharge policies.

Concerns summary Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.

Concerns summary Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure in emergency drug administration protocols for prisoners.

Concerns summary Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.

Concerns summary A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.

Concerns summary Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.

Concerns summary Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.

Concerns summary Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.

Concerns summary A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.

Concerns summary Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.

Concerns summary Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.

Concerns summary Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure in recognising the development of sepsis.

Concerns summary The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.

Concerns summary The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist shortages also contributed to backlogs.

Concerns summary The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Concerns summary A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.

Concerns summary The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Concerns summary Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.

Concerns summary There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.

Concerns summary Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.

Concerns summary Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing safety risks.

Concerns summary There was inadequate communication and history-taking during mental health assessments, failing to record critical self-harm attempts, and insufficient effort to find a suitable bed for a high-risk patient.

Concerns summary Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.