East London

Concerns summary Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with a profoundly learning disabled patient.

Concerns summary The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.

Concerns summary Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack of multi-agency risk assessment. There were also significant communication breakdowns between mental health services and the police.

Concerns summary Nursing failures included inadequate falls risk assessment, poor care-planning, and insufficient monitoring. Doctors also failed to decisively assess for intracranial bleeding or review warfarin post-fall.

Concerns summary Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.

Concerns summary No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for train operators and station staff unproven.

Concerns summary A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.

Concerns summary The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.

Concerns summary Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.

Concerns summary Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and intervention for victims.

Concerns summary Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to missed surveillance and preventable cancers.

Concerns summary Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also showed no evidence of identifying shortcomings or implementing remediation.

Concerns summary The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability to learn from adverse events.

Concerns summary A fatal iatrogenic injury went undetected due to extremely poor patient records, and the Trust's governance failed to identify the case for investigation, hindering learning and remediation of sub-optimal practice.

Concerns summary A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.

Concerns summary Delayed and disorganised staff emergency response, including failures to promptly raise alarms or call 999, coupled with inadequate CPR due to a misunderstanding of Do Not Resuscitate orders, led to critical care gaps.

Concerns summary Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence of bail conditions or driving disqualification.

Concerns summary GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.

Concerns summary Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped areas.

Concerns summary A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.

Concerns summary The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.

Concerns summary The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed sub-optimal practice.

Concerns summary The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, inadequate supervision, and substandard note-keeping, risking sub-optimal care for vulnerable individuals.

Concerns summary Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments for unaccepted patients are not audited, creating a safety net gap.

Concerns summary Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, posing a significant safety risk.