Public BoD papers 28.04.22

1. Safe

1.3 – Moderate+ Incidents

March 2022 Reference

Grade

Description

Outcome

W68197 2022/4942

Death

In patient cardiac arrest in patient with difficult airway

Clinical impact; patient has died. Clinical review of case underway

W68675 2022/7015

Recognised, consented, but unintended complication of surgical treatment

Death

Clinical impact, patient has died. Progressing to serious incident investigation.

W68787 2022/6974

Death

Cardiac arrest shortly following first cycle of chemotherapy

Clinical impact, patient has died. Progressing to serious incident investigation

Clinical impact; patient sustained fracture, transferred for surgical management. Progressing to full patient safety investigation

W68464 2022/5506

Inpatient fall resulting in neck of femur fracture

Major

Communication failure regarding abnormal blood results

Clinical impact; patient required inpatient admission. Progressing to full patient safety investigation.

W68402

Moderate

Clinical impact; patient required readmission. Progressing to full patient safety investigation.

Patient discharged without antibiotics

W68463

Moderate

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