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.