Failure to follow protocols (36) | Failure or delay in appropriate assessments | 19 (17) |
Failure to monitor treatment | 15 (13) |
Omission of necessary treatment | 13 (12) |
Delayed treatment | 12 (11) |
Failure to review medicines | 11 (10) |
Failure to take a history or see the patient | 10 (9) |
Failure or delay in performing necessary scans | 8 (7) |
Failure to triage patients appropriately | 7 (6) |
Failure to follow recommended practices | 6 (5) |
Failure to follow a protocol | 6 (5) |
Failure to review medical records | 4 (4) |
Failure to implement national guidelines | 3 (3) |
Administration of drug in error | 1 (1) |
Failure to arrange supervision | 1 (1) |
Inability to care for both a patient’s physical and mental health | 1 (1) |
Management of medication for care home residents | 1 (1) |
Medication administered despite known allergy | 1 (1) |
Communication (22) | Poor communication | 28 (25) |
Failure to keep accurate medical records | 28 (25) |
Failure to escalate deterioration in patient to the relevant medical professionals | 5 (4) |
Failure to seek specialist advice when indicated | 4 (4) |
Failure to follow the advice of a senior clinician | 2 (2) |
Failure to warn of the consequences of not taking medication | 2 (2) |
Failure to inform the patient about a medical procedure and aftercare | 2 (2) |
Failure to warn of adverse drug reactions | 1 (1) |
Failure to obtain informed consent | 1 (1) |
Safety (21) | Poor systems | 35 (31) |
Discharge process | 16 (14) |
Non-robust investigation following the death | 15 (13) |
Safety of facilities | 2 (2) |
Nature of inspections of care homes | 1 (1) |
Failure to address measures identified in risk assessment | 1 (1) |
Failure to make a reasonable effort to ensure patient adherence | 1 (1) |
Education and training (14) | Inadequate training | 12 (11) |
Inappropriate dosage for the patient | 9 (8) |
Failure to appreciate the risk (of giving or not giving a drug) | 6 (5) |
Lack of clinical knowledge | 5 (4) |
Poor clinical decision making | 5 (4) |
Poor awareness of symptoms | 4 (4) |
Poor awareness of rare ADRs | 2 (2) |
Poor awareness of rare complications of medical procedures | 1 (1) |
Failure of training | 1 (1) |
Drug awareness | 1 (1) |
Poor awareness of drug—drug interactions | 1 (1) |
Wrong method of administration | 1 (1) |
Resources (7) | Absence of national guidelines | 10 (9) |
Understaffing | 7 (6) |
Shortage or lack of availability of appropriate medical equipment | 3 (3) |
Hospital opening times or availability | 2 (2) |
Unavailable drug | 1 (1) |
Inability to deliver care | 1 (1) |