Brighton & Hove

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 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 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 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 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 The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Concerns summary The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Concerns summary The provided concerns text for this report does not detail specific safety issues or systemic failures related to the deceased's care at Carlton House Rest Home.

Concerns summary Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.

Concerns summary No specific concerns regarding future deaths were detailed in the provided text, only contact information.

Concerns summary Inadequate junior doctor training in sling application, lack of senior doctor review for high-risk patients, and failure to follow hospital discharge protocols for senior review and analgesia.

Concerns summary The provided text did not detail any specific concerns or systemic failures.

Concerns summary No specific concerns text was provided to summarise.

Concerns summary The provided text is incomplete and does not contain specific concerns.

Concerns summary A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.

Concerns summary No specific concerns or systemic failures were detailed in the provided text.

Concerns summary Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.

Concerns summary Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.