A patient bled to death on a ward at Shrewsbury and Telford Hospitals Trust after a device used to access his bloodstream became inexplicably disconnected, The Independent has learnt.
The incident came to light as new concerns arose about quality of care at the Shropshire trust, with the Care Quality Commission (CQC) warning of “serious concerns” about its medical wards and emergency department following an inspection last month.
Although the report from the inspection has not yet been published, it is understood that the trust has been served with a legal notice by the regulator to comply with more than a dozen conditions. It remains in special measures following the inspection and is rated inadequate overall.
The trust is at the centre of the worst maternity-care scandal in the history of the NHS, with more than 800 cases of alleged poor care being investigated by an independent inquiry. A leaked report last month showed widespread failings across a four-decade period.
An earlier inspection of maternity services, carried out in April, revealed concerns about a significant shortage of midwives, although the trust has since recruited 29 new staff.
The CQC said there were signs of improvement in maternity services when it revisited the trust in November.
It has been informed of the death of the patient who bled to death, and has the power to prosecute the trust for any breaches of safety rules.
An urgent investigation has now been launched by hospital bosses following the death in October.
The incident happened after a device known as a venous port became disconnected.
A venous port is a common device used in hospitals by doctors and nurses to access veins leading to the heart and to administer medication directly into the bloodstream.
Following a heart attack in June this year, the man, who has not been named, was admitted to intensive care and later required dialysis.
A meeting of the trust's board was told: “Whilst on the renal unit, by some means yet to be determined, the venous port became disconnected and the patient exsanguinated.”
The trust said the “high-profile case” had been reported to the Health and Safety Executive, the Medicines and Healthcare products Regulatory Agency and the Care Quality Commission.
A spokesperson for the trust told The Independent that the patient’s family had been informed.
Professor Ted Baker, the CQC's chief inspector of hospitals, said: “Inspectors highlighted serious concerns at the emergency departments and medical wards at the Princess Royal Hospital and Royal Shrewsbury Hospital during the current [November] inspection. As a result, CQC has taken further urgent action at the departments to protect the safety of patients.
“We are monitoring the trust extremely closely and continue to work with NHS England and NHS Improvement with regard to the trust. Our monitoring of the trust will include further inspections and we will not hesitate to take further action if needed.”
Paula Clark, chief executive of Shrewsbury and Telford Hospitals Trust, said: “In our emergency departments, we acted immediately on CQC findings by improving our processes, increasing specialist training for staff, and we have already appointed a sepsis nurse.
“But we recognise there is more to do and we are building a programme of improvement to address the areas of concern and ensure our patients receive the best possible care.”