Inadequate Recognition of Treatment Harm
22 items
1 source
Failure to adequately recognize and categorize the severity of adverse impacts from specific medical treatments.
Cross-Source Insight
Inadequate Recognition of Treatment Harm has been flagged across 1 independent accountability source:
22 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (22)
Amber Walker
Concerns: Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.
Response: The Department of Health and Social Care noted the concerns, referencing existing NICE guidance on epilepsies and the Clive Treacey Checklist for systematic SUDEP risk assessment. It also explained that …
Responded
Mary Pomeroy
Concerns: A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations for a high-risk patient.
Responded
Brian Beer
Concerns: NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.
Responded
Orlando Davis
Concerns: Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the baby.
Responded
Paz Ogbe-Millar
Concerns: Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Responded
Katie Williams
Concerns: The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate these medication interaction risks.
Responded
Sultana Choudhury
Concerns: Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Responded
Joshua Asprey
Concerns: Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this potential risk with patients.
Responded
Marjorie Walker
Concerns: A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.
Responded
Brian Jackson
Concerns: Delirium symptoms were missed due to reliance on a flawed CAM-ICU assessment tool, especially for certain presentations, risking suboptimal diagnosis and treatment for patients nationwide.
Overdue
Alvin Black
Concerns: Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.
Overdue
Carl Schmidt
Concerns: The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.
Responded
Pamela Hands
Concerns: A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.
Overdue
Pauline Taylor
Concerns: Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Overdue
James Kane
Concerns: A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes regarding such procedures.
Responded
Thomas Pearson
Concerns: A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.
Responded
Lynn Poyser
Concerns: Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Overdue
Barbara Harrison
Concerns: Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.
Overdue
Mrs Care
Concerns: Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.
Overdue
Susan Poore
Concerns: Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.
Overdue
Peter Jeffrey
Concerns: 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.
Pending
Peter Clive Higson
Concerns: Concerns arose regarding the detrimental effect of platelet transfusions following stem cell transplants, questioning if such transfusions might sometimes be contraindicated.
Response: NHSBT disputes the coroner's concerns, stating that TRALI was unlikely given the clinical timeline and donor antibodies. They assert that benefits of platelet transfusions outweigh risks in such cases and …
Response: The Department of Health, following advice from NHS Blood and Transplant, concluded that prophylactic platelet transfusion was appropriate for the deceased and that the respiratory deterioration was likely due to …
Pending