East London

Concerns summary Lengthy neurology waiting times, absence of mandatory annual GP epilepsy reviews, lack of clear national guidance for long-term monitoring, and poor communication of critical post-discharge information risk patient safety.

Concerns summary Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little meaningful reflection or remediation followed her death.

Concerns summary Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.

Concerns summary The GP surgery has failed to provide sufficient evidence that procedures for recording patient calls, escalating enquiries, and monitoring GP call-backs have improved since the death.

Concerns summary Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for darker skin tones pose risks.

Concerns summary Dangerous junior orthopaedic staffing and inaccessible NEWS charts during ward rounds meant consultants were unaware of deteriorating patient conditions. There was also confusion among doctors regarding patient responsibility.

Concerns summary Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.

Concerns summary The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.

Concerns summary Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a critically delayed radiological report.

Concerns summary Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.

Concerns summary A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.

Concerns summary Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.

Concerns summary Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation decision overlooked wider health problems.

Concerns summary Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing demand.

Concerns summary A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key risk factors.

Concerns summary A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.

Concerns summary There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding discharge risks and Body Dysmorphic Disorder (BDD) treatment. Training on BDD and its associated risks, including aesthetic dermatology, is insufficient, compounded by a lack of national BDD resources.

Concerns summary Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.

Concerns summary Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The emergency response was chaotic and staff records were found to be dishonest, indicating severe governance and care failures.

Concerns summary The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.

Concerns summary The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at increased self-harm risk, and did not ensure required weekly reviews.

Concerns summary Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.

Concerns summary Reduced enforcement against illegal e-scooter use correlates with increased fatalities, while legal riders aren't required to wear helmets. Inadequate or absent warnings from manufacturers about unlawful use exacerbate safety risks.

Concerns summary Senior nursing staff failed to implement comprehensive care plans, including capacity assessments for refusing observations, and critically, did not recognize or urgently respond to a patient's acutely deteriorating clinical condition.

Concerns summary There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental health crisis. FCDO travel advice is insufficient regarding the specific consequences of detention in Dubai.