East London

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 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 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 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.

Concerns summary The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.

Concerns summary Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.

Concerns summary Critical evidence (NG tube) was removed and lost prior to autopsy, and the Trust's investigation failed to adequately scrutinise this, compromising proper inquiry into the death.

Concerns summary Dental staff failed to recognise anaphylaxis symptoms, and allergy plans gave false reassurance for mild reactions. Education is needed on identifying anaphylaxis and using adrenaline auto-injectors if in doubt.

Concerns summary Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk management. Additionally, the existing risk assessment tool and alert systems proved to be unwieldy and ineffective.

Concerns summary There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge from mental health services, indicating staff lacked understanding of robust risk assessment and safety planning.

Concerns summary Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health deterioration and inadequate living conditions.

Concerns summary Qualified staff at the care home failed to follow the emergency choking protocol, and the subsequent internal investigation was criticised for its lack of thoroughness.

Concerns summary Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and controlled drug management systems were ineffective.

Concerns summary Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug interactions), and the diagnosis of serotonin syndrome.

Concerns summary Critical decisions were poorly documented, workload pressures led to a "coping culture," sedation decisions were flawed, and governance failed to identify and review a serious incident, compromising patient safety.

Concerns summary Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into the incident.