| Theme (% of concerns) | Concern | Cases, n (%) |
|---|---|---|
| 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) |
ADR = adverse drug reaction.