Essex

Concerns summary Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and auditing to prevent such systemic failures, risking future harm.

Concerns summary Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.

Concerns summary The patient was not informed of potential malignancy findings from a CT scan, leading to missed follow-up. Additionally, insufficient medical staffing caused delayed responses to urgent patient deterioration.

Concerns summary Roadworks safety procedures have flaws regarding distance calculations, inconsistent road markings, and a lack of requirement to report fatalities on permit applications, hindering safety assessments.

Concerns summary Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, medication reviews, and proper risk assessment.

Concerns summary Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.

Concerns summary A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary or safety netting advice for a vulnerable patient.

Concerns summary Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies in covert bleeding.

Concerns summary A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as required by protocol.

Concerns summary A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and follow up referrals led to significant care failures.

Concerns summary The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment training.

Concerns summary Despite consolidated rotas, there's an overall insufficiency of doctors in Emergency and Paediatrics Departments, with only 60% staffing, raising concerns about service capacity.

Concerns summary The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex foreign body removal. A lack of urgency and failure to recognise her deteriorating clinical condition contributed to critical delays.

Concerns summary Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, and policy for 1:1 observation is confusing, leaving a critical protocol gap.

Concerns summary A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge summary, leading to delayed care.

Concerns summary Repeated significant delays in medical reviews, commencement of antibiotics, and failure to follow the sepsis protocol led to compromised care.

Concerns summary An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created unsafe backlogs and sub-optimal care, persisting years after the death.

Concerns summary A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk assessment, and medication risks with alcohol were not communicated. Inconsistent recording of alcohol consumption and ignored family concerns compromised patient safety.

Concerns summary Support workers providing 24-hour solo care to vulnerable clients lack mandatory certificated First Aid and Basic Life Support training, posing a significant risk of future deaths.

Concerns summary Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the patient's carer.

Concerns summary Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured risk management tools. British Transport Police's multi-agency support plan also failed to communicate railway station attendances, especially from unstaffed stations.

Concerns summary The Trust's investigation was incomplete and delayed, failing to address critical issues like inadequate staff observations and security breaches on a locked mental health ward. A dispute over permitted items and failure to escalate risk were also concerns.

Concerns summary Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.

Concerns summary A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.

Concerns summary A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.