Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.

Concerns summary An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient placement.

Concerns summary Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.

Concerns summary Catastrophic failures in chest drain insertion included unlabelled and misinterpreted chest X-rays, incomplete review of images, and a lack of patient examination prior to the procedure.

Concerns summary Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.

Concerns summary The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.

Concerns summary The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.

Concerns summary The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.

Concerns summary A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.

Concerns summary Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of Abortion Act amendments. Foeticide should be considered before induction at this stage.

Concerns summary Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate treatment and a lack of necessary barrier nursing, highlighting failures in inter-hospital documentation.

Concerns summary Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content and potential for ingestion, posing a significant safety risk.

Concerns summary A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is a delay in finalising and implementing updated national guidance for neonatal hypoglycaemia management.

Concerns summary A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.

Concerns summary Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.

Concerns summary Inconsistent use of customised growth charts and poor recording of fundal height measurements between two NHS trusts obscured fetal growth assessment. Crucially, despite clear indications of below-normal growth, no referral for further specialist opinion or scan was made.

Concerns summary The coroner raised concerns about the diagnostic challenges of acute appendicitis in very young children, emphasizing the need for improved recognition pathways even when experienced clinicians assess rare conditions.

Concerns summary The concerns text provided for this report was incomplete, preventing a summary of specific issues.

Concerns summary The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.

Concerns summary Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, impacted patient care and readiness for surgery.

Concerns summary Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.

Concerns summary Significant systemic failures included inadequate consultant on-call cover, poor trainee supervision, delayed emergency admission reviews, and critical failures in sepsis recognition, escalation, and safe propofol management.

Concerns summary Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify these ongoing administrative issues affecting patient care.

Concerns summary Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.

Concerns summary Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.