AN ANNUAL report looking into deaths at the John Radcliffe's hospital trust has found two were ‘more likely than not’ due to problems in the care the patient received.

Issues with communication between departments, ward notes and staff not catching complications were highlighted in the Oxford University Hospitals NHS Foundation Trust document.

The first patient mentioned in the report died after coming in with a stroke and developing a 'hyperosmolar hyperglycaemic state'.

According to the Diabetes UK website this occurs in people with Type 2 diabetes who experience very high blood glucose levels and can develop over weeks through a combination of illness and dehydration.

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The report explained: “Multiple professional groups did not recognise that the patient was becoming dehydrated and was developing a hyperosmolar hyperglycaemic state.”

It added: “The need to pay attention to hypernatraemia [high concentration of sodium in the blood] when the patient was hyperglycaemic has been highlighted to teams."

The second case was of a patient with learning disabilities.

The review found that a delay in recognising a complication following the insertion of a nasogastric tube, which helps give nutrition through a tube going into the stomach via the nose, was ‘likely to have directly contributed to death’.

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The report stated the case was investigated as a 'Serious Incident Requiring Investigation' and that immediate lessons from the death included improving staff understanding of complications from inserting the tube, the need for improved documentation on ward rounds and during discussions with the patient’s family, as well as improved communication between the Radiology and General Medicine teams.

Meghana Pandit, Chief Medical Officer at the trust, said: “In the sad cases of the two patient deaths, we take these cases very seriously and both were reported to the relevant regulators, investigated thoroughly, and discussed with the patients’ families.

"Direct actions were taken to improve care in these areas and learning points disseminated throughout the relevant departments."

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The report also revealed that of the 2,674 inpatient deaths reported at the trust in 2018/19 just over one in 10 – 11 per cent – were not carried out within eight weeks.

Ms Pandit said: “We are working closely with clinical and governance staff throughout the trust to increase the number of death reviews completed in the given timeframe.

“We continue to learn and improve from these reviews and carried out the vast majority of them in a timely manner, which means we can implement any changes or learning promptly."

The report also confirmed the trust would be putting in place a medical examiner system, from April next year.

Ms Pandit said the medical examiner role would 'streamline and improve' mortality review services as well as offering 'greater support' to bereaved families.