2015

Concerns summary Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.

Concerns summary Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.

Concerns summary The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing future deaths.

Concerns summary Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.

Concerns summary Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher observation standards previously in place would likely have prevented the death.

Concerns summary There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.

Concerns summary The cot side on a trolley could remain in an unlocked position due to design and maintenance issues, which were not clearly highlighted. The MHRA failed to escalate this known hazard to other hospital trusts.