Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.

Concerns summary The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.

Concerns summary The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.

Concerns summary Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.

Concerns summary The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.

Concerns summary Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.

Concerns summary Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling and timely response to basic needs, causing distress.

Concerns summary The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.

Concerns summary A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.

Concerns summary Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance regarding dehydration in children.

Concerns summary A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.

Concerns summary A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not a mental health service.

Concerns summary A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in emergency assistance.

Concerns summary Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment for an aortic dissection, contributing to the patient's death.

Concerns summary Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.

Concerns summary The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of improvements from an agreed action plan was demonstrated.

Concerns summary Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical deterioration, despite prior similar omissions.