Brighton & Hove

Concerns summary The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.

Concerns summary There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are often denied adequate support.

Concerns summary Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.

Concerns summary There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.

Concerns summary Inadequate management of a patient's deteriorating condition, including unmanaged hypoglycaemia and failure to transfer to critical care, was exacerbated by poor escalation of care when the primary consultant was unavailable.

Concerns summary Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered an urgent cardiology referral.

Concerns summary Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).

Concerns summary Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about highway safety for those crossing the road.

Concerns summary The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective treatment.

Concerns summary The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.

Concerns summary Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.

Concerns summary Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.

Concerns summary No specific concerns related to future deaths were detailed in the provided text.

Concerns summary The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.

Concerns summary There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.

Concerns summary The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised improvements from previous PFD reports concerning transfer protocols.

Concerns summary The fact that a member of the public discovered the body on the railway platform raises concerns about monitoring and detection systems.

Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Concerns summary Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.

Concerns summary Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.

Concerns summary Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised employee performing dangerous tasks without risk assessments. There was also a lack of first aid provision and management training.

Concerns summary Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.

Concerns summary No specific concerns text was provided for summarization.

Concerns summary Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.

Concerns summary Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.