Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.

Concerns summary A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.

Concerns summary Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.

Concerns summary Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.

Concerns summary A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.

Concerns summary Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.

Concerns summary The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.

Concerns summary An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.

Concerns summary Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.

Concerns summary Urgent blood test results were not acted upon promptly, leading to a delay in necessary hospital admission.

Concerns summary Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.

Concerns summary Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.

Concerns summary The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.

Concerns summary Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.

Concerns summary Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.

Concerns summary Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.

Concerns summary A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care unit lacked access to electronic hospital notes, impeding effective treatment.

Concerns summary The provided concerns text is too truncated to identify specific safety issues.

Concerns summary Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units to minimise this risk.

Concerns summary A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.

Concerns summary Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.

Concerns summary A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and a 'nil by mouth' decision was made with insufficient evidence.

Concerns summary Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.

Concerns summary After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent death by suicide.