Inadequate Pre-Operative Risk Assessment
Insufficient pre-operative assessments and specialist reviews for patients with significant comorbidities, risking complications.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
GIRFT recommendation
90match
Anaesthesia and Perioperative Medicine
Ensure that day case surgery is the default for all suitable elective surgical procedures. a Ensure patients are made aware in primary care at time of referral for possible surgery that their procedure is likely to be conducted as a day case. b Confirm or establish a dedicated preoperative assessment and preparation process for the day case surgery...
Matched on
terms: assessment, operative, pre
PFD report
89match
Betty Smith
The coroner identified insufficient ITU bed capacity due to nursing shortages, inadequate anaesthetic pre-assessment for high-risk patients relying solely on medical records, and the failure to secure a High Dependency Unit bed post-operatively for such a patient.
Matched on
terms: assessment, inadequate, operative, pre
PFD report
85match
Neil Westerman
A junior doctor performed the pre-operative assessment, leading to the consultant being unaware of vital information, and operation notes lacked details of equipment used. There were also insufficient junior doctors on duty, particularly at night.
Matched on
terms: assessment, operative, pre
HSSIB recommendation
85match
Surgical care of NHS patients in independent hospitals
It may be beneficial if NHS and independent sector organisations delivering NHS-funded surgical interventions reviewed their procedures and practice in light of the published 2021 guidance for ‘Preoperative Assessment and Optimisation for Adult Surgery’. Such a review should take into account: Individualised risk assessment using objective measures to support decisions about patient suitability for surgery and escalation for...
Matched on
terms: assessment, operative, pre
PFD report
81match
Patricia Mellor
The coroner raises concerns that the Medicines and Healthcare Products Regulatory Agency (MHRA) and NICE have not acted on recommendations to update product information warnings for anaesthetic agents and revise pre-operative assessment guidelines concerning Long QT Syndrome.
Matched on
terms: assessment, operative, pre
GIRFT recommendation
81match
Orthopaedic Surgery
All hip fracture and TKR patients should receive a multidisciplinary assessment pre-operatively to determine achievable goals of rehabilitation.
Matched on
terms: assessment, operative, pre
PFD report
77match
Rosina Drury
The coroner noted that the absence of a pre-operative orthogeriatric review for patients with a fractured neck of femur may lead to the use of cemented hemiarthroplasty, which carries a risk of mortality from bone cement implantation syndrome.
Matched on
terms: operative, pre
PFD report
73match
Annie Jones
The coroner noted an inadequate mobility assessment for Mrs Jones, leading to her unsafe placement in a stand aid while non-weight-bearing. Concerns also included insufficient staff awareness of her limitations and safe equipment operation.
Matched on
terms: assessment, inadequate
PFD report
73match
David Greenfield
The coroner noted staff lacked appreciation for respiratory depression risks in patients with co-occurring drug and alcohol problems. Admission procedures for alcohol detoxification also lacked drug screening, hindering proper risk assessment for those known to take other substances.
Matched on
terms: assessment, pre
PFD report
73match
Sharon Henshall
The coroner identified the absence of a venothromboembolism risk assessment model in the Emergency Department for patients discharged with lower limb immobilisation, noting a 'postcode lottery' in prophylaxis across different Trusts and inconsistency with NICE guidance.
Matched on
terms: assessment, pre
PFD report
73match
Joshua Knox-Hooke
The coroner identified inadequate observation of a patient at risk of self-harm and frequent instances of patients leaving A&E before psychiatric assessment. It was also noted that a triage nurse was unaware of Mental Health Act holding powers.
Matched on
terms: assessment, inadequate
GIRFT recommendation
73match
Respiratory Medicine
Increase the use of Cardiopulmonary Exercise Testing (CPET) with interpretation by senior physiologists to manage breathlessness and determine patients' fitness for major or complex surgery. a) Ensure access to CPET for managing complex and unexplained breathlessness. b) Review current levels of CPET activity and agree protocols to ensure preoperative testing is optimised. c) Review international evidence around CPET...
Matched on
terms: operative, pre
CQC action
72match
Northern General Hospital
The trust should consider expanding the audit programme to include the assessment of pain and the use of preoperative fasting.
Matched on
terms: assessment, operative, pre
HSSIB recommendation
69match
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that the Royal College of Anaesthetists reviews standards for pre-assessment services, including their purpose, the required observations and examinations, and competencies of staff undertaking this work.
Matched on
terms: assessment, pre
GIRFT recommendation
69match
Vascular Surgery
Improve prehabilitation for AAA, PVD and CEA, particularly with regards to perioperative medical input. 8A: Clinicians and providers to improve use of multidisciplinary prehabilitation using known best practice. 8B: GIRFT to inform NICE of proposed changes to practice linked to this recommendation for consideration in development of NICE Guideline Abdominal aortic aneurysm: diagnosis and management. 8C: NHSE Specialised...
Matched on
terms: operative, pre
CQC action
69match
BMI Southend Private Hospital
The provider must ensure that risks to patients are identified through surgical pre-assessment prior to surgery being undertaking under local anaesthetic.
Matched on
terms: assessment, pre
GIRFT recommendation
68match
Diabetes
All hospital trusts should have clear, audited perioperative pathways from pre-assessment through to discharge. These should be broadly in line with NCEPOD recommendations.
Matched on
terms: assessment, operative, pre
PFD report
65match
John Fox
Reduced physiotherapy services on bank holidays and weekends pose an increased risk of post-operative complications for vulnerable patients.
Matched on
terms: operative
PFD report
65match
Bryan Catanach
The coroner raised concerns about communication difficulties between clinicians and hospital trusts, leading to delayed patient transfers and reviews. Issues also included a patient falling from bed due to inadequate supervision for an unstable neck fracture.
Matched on
terms: inadequate
PFD report
65match
Ronald Bentley
The coroner identified a lack of widespread awareness among cardiologists and device manufacturers regarding the risk of air entering the vascular system during a specific cardiac procedure when performed under conscious sedation. This unknown risk could lead to future complications for patients at other Cardiac Centres.
Matched on
terms: pre
PFD report
65match
Kirsty Childs
Concerns were raised regarding the absence of a standard question to identify previous patient contacts, the selection of incorrect questionnaires by non-medically qualified staff, and no review of earlier calls within NHS Direct.
Matched on
terms: pre
PFD report
65match
Harry Glibbery
The coroner noted a doctor did not prescribe Clexane according to protocol, and this error was not identified during pharmacy reviews. Concerns were also raised about difficulties in weighing patients, which is crucial for weight-dependent medication.
Matched on
terms: pre
GIRFT recommendation
65match
Paediatric Trauma and Orthopaedic Surgery
Implement specific recommendations to reduce litigation costs for paediatric T&O. a Institute consent/pre-operative clinics to ensure maximum understanding of risks and benefits of proposed procedures b Use standard neurovascular observation record charts for limb injuries, particularly supracondylar fractures c Ensure that the pathway for DDH screening and surveillance is robust to avoid late diagnoses. d Avoid incidents from...
Matched on
terms: operative, pre
CQC action
64match
Andover War Memorial Hospital
The provider should act and review the process for fasting pre-operatively in line with guidelines.
Matched on
terms: operative, pre
LGO / SPSO decision
62match
PSOW-202000167 - Aneurin Bevan University Health Board
Mr L complained about the care provided to his late mother, Mrs M, when she was an inpatient in November 2019. Specifically, Mr L complained that the Health Board failed to monitor and treat Mrs M’s breathlessness properly; failed to provide her with adequate support to use the toilet; did not give enough consideration to meeting Mrs M’s...
Matched on
terms: assessment, inadequate, pre
PFD report
61match
Carol Walker
The coroner noted it was not standard practice at Harrogate District Hospital to routinely administer chemical thrombo prophylaxis or undertake formal venous thromboembolism risk assessments for patients with conservatively treated lower limb injuries in casts.
Matched on
terms: assessment
PFD report
61match
Martin McCabe
No falls risk assessment was carried out upon the patient's admission to ward 15, with staff relying on an outdated assessment that did not include crucial information about recent falls and new medication.
Matched on
terms: assessment
PFD report
61match
Robert Stuart and Darren Hughes
The coroner identified insufficient transmission of comprehensive donor information and microbiology reports to the transplant centre. Concerns also included the accepting consultant not using the full electronic system and making unilateral decisions without a team approach.
Matched on
terms: pre
PFD report
61match
Nicola Tweedy
The coroner noted the absence of specific aftercare leaflets provided to the patient, the consistent non-completion of the Thromboprophylaxis Risk Assessment form, and incomplete nursing notes and checklists at the point of discharge.
Matched on
terms: assessment
PFD report
61match
Patricia Holmes
The A&E doctor's assessment did not adequately consider the risk of internal bleeding for a patient with trauma and multiple fractured ribs, who was also receiving anticoagulation therapy.
Matched on
terms: assessment
PFD report
61match
Karen O’Brien
The coroner noted concerns regarding a clinical determination made by SEPT without a face-to-face mental health assessment or sufficient inquiry, overriding the patient's GP's request. The report also invited NICE to reconsider its guideline on this matter.
Matched on
terms: assessment
PFD report
61match
Casey Garrett
The coroner noted inappropriate midwifery care by a student midwife, including insufficient fetal monitoring and CTG misinterpretation, alongside a failure to escalate care. This raised questions about Bedford Hospital's suitability as a clinical learning environment.
Matched on
terms: pre
PFD report
61match
Mary James
The coroner noted inadequate monitoring of INR levels and uncertainty regarding Warfarin adherence for a patient with dementia. There were also concerns about communication gaps between the INR Unit, care home, and GP, and a missed opportunity for hospital admission to adjust anticoagulation therapy.
Matched on
terms: inadequate
PFD report
61match
Eileen Smith
Failings in nursing care were identified for a patient with learning disabilities, alongside inadequate communication with their carers and family. The report also raised concerns about assumptions made regarding the health of individuals with learning disabilities.
Matched on
terms: inadequate
PFD report
61match
Darren Jones
Current protocols for when to seek renal advice for patients, particularly those who have undergone transplants, are limited, and there are questions regarding the availability of immunosuppressant medication at short notice.
Matched on
terms: pre
PPO recommendation
60match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking and reviewing risk assessments for prisoners taken to and admitted to hospital understand the legal position, that assessments fully take into account prisoners’ health and are based on the actual risk they present at the time.
Matched on
terms: assessment, pre
PFD report
57match
Laura Hill
Falls Risk Assessments were not carried out for Mrs Hill during her hospital stay, specifically on admission or ward transfer, despite existing staff training on the procedure.
Matched on
terms: assessment
PFD report
57match
Rebecca Jones
The coroner identified that the Section 136 assessment for Rebecca Jones was not conducted within the expected three-hour timeframe. This delay occurred because urgent assessments were required for other vulnerable persons, indicating a potential capacity issue at the facility.
Matched on
terms: assessment
PFD report
57match
Stephen Adams
The coroner noted that the suicide risk assessment section on the Mental Health Liaison Team's risk assessment document was frequently left incomplete, requiring risk to be inferred from actions rather than explicitly recorded.
Matched on
terms: assessment
PFD report
57match
Lincoln Brady
The coroner noted that non-correlating examination results were not further investigated with an ultrasound, leading to an undiagnosed breech presentation and preventing appropriate planning for delivery.
Matched on
terms: pre
PFD report
57match
Rhianne Barton
The coroner identified a lack of obstetric consultant supervision and a failure to consider surgical causes for abdominal pain following bariatric surgery. Concerns were also raised about poor clinical documentation, unaddressed urine dipstick findings, and a lack of specific guidance for managing pregnancy post-bariatric surgery.
Matched on
terms: pre
GIRFT recommendation
57match
General Surgery
Require reversible risk factors to be addressed prior to non-urgent procedures, using a patient-centred approach utilising shared decision-making. Actions: 9A: Guidance to be developed by GIRFT on the management of reversible risk factors prior to surgery, with the involvement of the Royal College of Surgeons of England (RCSE) and the Association of Surgeons of Great Britain and Ireland...
Matched on
terms: operative
PPO recommendation
56match
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints, that healthcare staff complete the medical information section of the escort risk assessment in full, and that assessments fully take into account the health of a prisoner and are based...
Matched on
terms: assessment, pre
PPO recommendation
56match
The Governor
The Governor should ensure that authorising managers understand the legal position on the use of restraints and that assessments fully take into account the health of a prisoner and are based on the actual risk the prisoner presents at the time.
Matched on
terms: assessment, pre
PPO recommendation
56match
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: all staff involved in the escort risk assessment process receive training on the Graham judgment and have a clear understanding of how it applies to the Prevention of Escape – External Escorts policy framework;
Matched on
terms: assessment, pre
PPO recommendation
56match
The Director
all staff undertaking risk assessments for prisoners attending hospital understand the legal position on the use of restraints, including that their assessments fully take into account the prisoner’s health and mobility, and are based on the actual risk the prisoner presents at the time;
Matched on
terms: assessment, pre
PHSO casework decision
56match
P-004325 - University Hospitals Birmingham NHS Foundation Trust
Complaint alleged inappropriate treatment of pregnancy-induced hypertension, inadequate monitoring, failure to administer epilepsy medication, and sterilisation performed without informed consent during childbirth.
Matched on
terms: inadequate, pre
PPO recommendation
55match
The Governor of HMP Hull
escort staff should question the escort risk assessment and review previous assessments if there are clear indications that restraints should not be used;
Matched on
terms: assessment, pre
PPO recommendation
55match
The Governor of HMP Wormwood Scrubs
The Governor should review Wormwood Scrubs’ policy on escort risk assessments for emergency hospital journeys to ensure that staff take account of a prisoner’s presenting medical condition, as well as public protection factors, when considering the level of restraints.
Matched on
terms: assessment, pre
LGO / SPSO decision
54match
PSOW-202300527 - Betsi Cadwaladr University Health Board
Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital (“the Hospital”) in July 2022 . Ms A had several medical conditions, including epilepsy (a condition which causes seizures), cerebral palsy (a condition that affects movement and co-ordination) and learning disabilities. She lived in a nursing home, had limited communication, and...
Matched on
terms: assessment, inadequate, pre