Sentinel 11 Patient in Review found that the patient’s The review made no recommendations. Police referred to Coroner at time community. Patient had assessment was fully of event (as death occurred in been admitted that day completed and the appropriate community). for suspected deep vein treatment pathway was thrombosis (DVT clot). commenced prior to the leave. – The patient had been The decision to allow the leave allowed short-term leave was based on established to return for ultrasound practice of treating such scan. Patient died a few patients on an outpatient hours after taking leave. basis. The review team consider this patient received appropriate care and did not identify any deviation from usual practise. The review team concluded that the DVT pathway is appropriate and supported by current practice and no modifications were required. Serious 4F Patient required Medical Review in progress. Emergency Team call upon arrival in ward after transferring from the Emergency Department. Serious 4B Patient admitted within Review in progress. 24 hours of procedure (angiogram). Patient deterioration and death. Concerns regarding and level of care.
Sentinel 11 Patient in community. Patient had been admitted that day for suspected deep vein thrombosis (DVT – clot). The patient had been allowed short-term leave to return for ultrasound scan. Patient died a few hours after taking leave. Review found that the patient’s assessment was fully completed and the appropriate treatment pathway was commenced prior to the leave. The decision to allow the leave was based on established practice of treating such patients on an outpatient basis. The review team consider this patient received appropriate care and did not identify any deviation from usual practise. The review team concluded that the DVT pathway is appropriate and supported by current practice and no modifications were required. The review made no recommendations. Police referred to Coroner at time of event (as death occurred in community). Serious 4F Patient required Medical Emergency Team call upon arrival in ward after transferring from the Emergency Department. Review in progress. Serious 4B Patient admitted within 24 hours of procedure (angiogram). Patient deterioration and death. Concerns regarding and level of care. Review in progress.
SSE-cases-2010-11-FINALv1.docx