Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.

Concerns summary A malfunctioning operating table and emergency stop, potentially linked to a damaged, improperly positioned handset, highlight inadequate pre-operation checks and a lack of training or hospital-wide review for similar equipment.

Concerns summary Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety recommendation for such caps was ignored, and no cap counting procedure exists.

Concerns summary The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.

Concerns summary Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.

Concerns summary Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.

Concerns summary Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with scanty hospital notes, created significant misunderstandings and risks.

Concerns summary An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.

Concerns summary The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.

Concerns summary Hospital procedures for seriously injured trauma patients require urgent review, specifically concerning summoning on-call clinicians, CT scanning protocols, and minimizing delays to theatre for surgery.

Concerns summary Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.

Concerns summary Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.

Concerns summary Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring and making accessible essential patient information.

Concerns summary Hospital staff failed to consider alternative diagnoses or treatments, did not take cultures from an infected blister, and overlooked intravenous antibiotics after negative DVT scans.

Concerns summary Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.

Concerns summary Critical deficiencies exist in the emergency department, including inadequate availability and consistency of emergency airway equipment, insufficient backup instruments, poor out-of-hours theatre access, and inadequate night staffing.

Concerns summary The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.

Concerns summary Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.

Concerns summary The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.

Concerns summary Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.

Concerns summary Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.

Concerns summary Wheeled chairs accessible to elderly patients caused falls, and a shortage of alarms for high-risk patients meant they could mobilize unsupported.

Concerns summary Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.

Concerns summary A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.