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.
PFD report
89match
Betty Smith
Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.
Matched on
terms: assessment, inadequate, operative, pre
PFD report
85match
Neil Westerman
Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, especially 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
77match
Annie Jones
An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, posing a significant risk of injury to vulnerable patients.
Matched on
terms: assessment, inadequate
PFD report
77match
Rosina Drury
The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.
Matched on
terms: operative, pre
PFD report
73match
Sharon Henshall
The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Matched on
terms: assessment, pre
PFD report
69match
Stephen Adams
Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.
Matched on
terms: assessment, inadequate
PFD report
69match
Bryan Catanach
Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Matched on
terms: inadequate
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
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
PFD report
65match
John Fox
Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Matched on
terms: operative
PFD report
65match
David Greenfield
Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, hindering proper risk assessment.
Matched on
terms: assessment
PFD report
65match
Darren Jones
The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with the education of staff and availability of immunosuppressant drugs.
Matched on
terms: pre
PFD report
65match
Harry Glibbery
The doctor did not prescribe Clexane in accordance with Derriford Protocol, this was not identified during Pharmacy reviews, and there were difficulties weighing patients whose medication is weight-dependent.
Matched on
terms: 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
Jennifer Rushworth
Significant delays in cardiology reviews, lack of surgeon input in theatre booking, and insufficient surgeons contributed to surgical delays, potentially impacting patient outcomes.
Matched on
classifier match
PFD report
61match
Laura Hill
Despite existing training, Falls Risk Assessments were not carried out for the patient during her entire hospital stay, including upon admission and ward transfer.
Matched on
terms: assessment
PFD report
61match
Carol Walker
Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.
Matched on
terms: assessment
PFD report
61match
Nicola Tweedy
Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. Discharge notes were also incomplete and checklists unfulfilled.
Matched on
terms: assessment
PFD report
61match
Patricia Holmes
The A&E doctor failed to recognize the serious risk of internal bleeding in a patient with multiple fractured ribs and on anticoagulation therapy, leading to inadequate action for their condition.
Matched on
terms: inadequate
PFD report
61match
Casey Garrett
Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.
Matched on
terms: pre
PFD report
61match
Mary James
Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Matched on
terms: inadequate
PFD report
61match
Joshua Knox-Hooke
The patient was not kept within eyesight at all times as required by Trust policy, and it is common for patients to leave A&E prior to psychiatric assessment; the triage nurse was unaware of nurses' holding power under the Mental Health Act.
Matched on
terms: assessment
PFD report
61match
George Watson
Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.
Matched on
terms: inadequate
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
Martin McCabe
The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.
Matched on
terms: assessment
PFD report
57match
Karen O’Brien
The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Matched on
terms: assessment
PFD report
57match
Rebecca Jones
Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.
Matched on
terms: assessment
PFD report
57match
Ronald Bentley
A previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.
Matched on
terms: pre
PFD report
57match
Lincoln Brady
Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Matched on
terms: pre
PFD report
57match
Rhianne Barton
Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National guidelines on bariatric surgery in pregnancy are also lacking.
Matched on
terms: pre
PFD report
57match
Diana Ritchie
Mrs Ritchie was recovering from major surgery and on her second day post operatively was suspected of having an Ileus.
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
PFD report
53match
Lucy Kilvert
A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
Matched on
classifier match
PFD report
53match
Herta Woods
Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.
Matched on
classifier match
PFD report
53match
Stephen Mayoll
The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Matched on
classifier match
PFD report
53match
Rosalind Baird
There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Matched on
classifier match
PFD report
53match
Jean Stockley
Despite a deteriorating respiratory condition and a rising NEWS score, a junior doctor did not review the patient, and it was unclear whether the appropriate doctor had been contacted; the coroner suggested a potential training need.
Matched on
classifier match
Scottish FAI
53match
Andrew Ritchie, Agnes Nicol and George Johnstone
It is essential that every doctor and nurse responsible for the care of a patient has access to all the records and all the documents and that full notes are available at all times. I can only hope that NHS Lanarkshire will ensure in future that, firstly there is full documentation recorded by both the doctors and nurses...
Matched on
classifier match
PPO recommendation
52match
The Head of Healthcare
The Head of Healthcare should review the systems and processes for training and supporting staff to complete escort risk assessments for patients requiring emergency hospital admission.
Matched on
terms: assessment
PHSO casework decision
51match
P-002012 - Birmingham Women's and Children's NHS Foundation Trust
The Trust provided inadequate assessments and treatment before her cancer diagnosis, caused a cyst rupture during surgery, and communicated poorly.
Matched on
terms: assessment, inadequate
PHSO casework decision
51match
P-003083 - George Eliot Hospital NHS Trust
Staff delayed checking preoperative samples, discharged partner without treatment for a broken hip, gave no condition updates, prohibited family visits, and didn't assist with bed transfers.
Matched on
terms: operative, pre
LGO / SPSO decision
50match
PSOW-202005555 - Swansea Bay University Health Board
Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with a sarcoma (a rare type of cancer). She was referred to a specialist...
Matched on
terms: operative, pre