Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new clinical settings.

Concerns summary Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. Poor record-keeping and absence of an internal investigation were also identified.

Concerns summary Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.

Concerns summary Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a different team and not returning to the operating hospital for essential follow-up.

Concerns summary Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.

Concerns summary Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training program and policy for preventing untrained bank staff from working are significantly delayed.

Concerns summary A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.

Concerns summary A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.

Concerns summary The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.

Concerns summary Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for specific requests. This issue, not fully addressed in an After Action Report, risks future diagnostic errors.

Concerns summary Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.

Concerns summary There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.

Concerns summary Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.

Concerns summary The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led to significant delays in diagnosis and appropriate antibiotic treatment.

Concerns summary Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests highlighting similar electrolyte monitoring failures.

Concerns summary Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney transplant patients.

Concerns summary Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.

Concerns summary Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed diagnosis and treatment of conditions like Acute Fatty Liver of Pregnancy.

Concerns summary Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this diagnosis for abdominal pain.

Concerns summary A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.

Concerns summary There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.

Concerns summary The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.

Concerns summary Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.

Concerns summary A high-risk patient suffered from inadequate pressure area care, including missed repositioning and an incomplete wound care plan. The subsequent investigation failed to identify the root causes of these critical care gaps.

Concerns summary Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.