Table 3.

Examples of the acute medical unit severe harm and death reports from the National Reporting and Learning System.

Example 1

Missed diagnosis of MI – ECG had ST elevation, delay to thrombolysis.

Example 2

MEAU. Patient admitted with a headache of sudden onset. CT was reported as normal when subtle blood was visible. [Lumbar puncture] not done by medical team. Patient discharged but readmitted with massive subarachnoid haemorrhage and died.

Example 3

GP referral with central chest pain, radiating to left arm, troponin test was elevated, seen by on call physician and sent home, continued to have chest pain readmitted to CCU with substantial further rise in troponin and widespread ECG changes

Example 4

Patient was prescribed ACS treatment as? NSTEMI positive trop T. The aspirin 300 mg, clopidogrel 300 mg and fondaparinux 2.5 mg were not signed for on Cerner or on any paper chart which points to a missed dose.

Example 5

Admitted generally unwell. Referred in with a raised INR (8.8), repeat INR 8.3. Delay in recognition of elevated INR (missed in clerking and post take ward round). Identified on evening [night round]. Vit K prescribed but not given.

Example 6

Patient prescribed IV Augmentin. First dose given at 03:10 approx. Patient later arrested and died. As patient appeared to be fitting, I checked the drug chart for Diazemuls to realise she was penicillin allergic. An arrest call was put out and doctors informed of allergy. Patient immediately given IV [adrenaline] and hydrocortisone 200 mg IV. CPR was not successful, and patient died.

Example 7

Patient referred by GP with a diagnosis of acute renal failure and urinary sepsis, arrived at hospital 16:30, initial bloods showed [creatinine] 812 and [potassium] 7.8, [arterial blood gas] showed lactate 8.1. Unclear to what extent this was recognised and treated over the 9 h from admission – the drug chart did not show any treatments running – patient remained anuric and became increasingly hypotensive then had a cardiac arrest at 01:30. Transiently resuscitated with adrenaline but then re-arrested and died.

Example 8

[Patient] presented 16:30 with urosepsis (septic shock). Treated with fluids and IV antibiotics, but failed to maintain parameters (HR, BPP, HR, SATS). No further entry in the notes after clerking. No handover to night SpR. Nurse on shift no handover from colleague for further medical involvement. Called to see patient peri-arrest. Failed to resuscitate after 1 h and 1 return of circulation midway. Stopped due to multiorgan failure, aspiration, futility and failure to re-establish output.

Example 9

Patient admitted on [date] with sepsis. She was referred to outreach due to deteriorating observations. It was found later that the patient had MRSA but she could not be transferred to side room for barrier nursing due to needing high dependency care. She later needed to be transferred to ITU but no beds available and the [patient’s] condition continued to deteriorate. She died [three days later] with neither transfer to ITU taking place and or a decision being made to withdraw care. There were no hourly observations carried out prior to death.

Example 10

Patient admitted on [date 1] at 13:00 to A&E with fall. Cardiac [observations] recorded at 13:10, [track and trigger] score of 2 next set in A&E at 16:05 [track and trigger] score of 2. [Patient] transferred to CDU; seen by medical team at 18:30 no observations recorded on admission to CDU. [Patient] suffered cardiac arrest at 06:48 a.m. on the [next day]. No observations recorded from 16:05 on [date 1] until post arrest the [next morning]. Patient [died] (on end of life care) on [3 days later].

Example 11

[Patient] transferred from A&E at 15:45 h, staff nurse from A&E given handover about [patient] to [specialist nurse]. The [specialist nurse] was told that [patient] had been admitted with right-sided weakness and headache, nurse was not informed that [patient] had chest pain or that an ECG taken whilst [patient] in A&E indicated that [patient] experienced anterior myocardial infarction. [Patient] experienced a respiratory arrest whilst being seen by [doctor].

Note: Exemplar quotes have been pseudoanonymised and spelling corrected for clarification purposes. In some cases, this required removal of data elements (e.g. a rare condition). Edits are indicated in square brackets with […] indicating the need to remove identifiable data.