Inner North London

Concerns summary The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.

Concerns summary There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.

Concerns summary There was a lack of clear guidance for community nurses on GP involvement and significant systemic failures in sharing patient information and escalating concerns between various healthcare and care provider agencies.

Concerns summary The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure to properly investigate a patient arrest raised serious safety concerns.

Concerns summary Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.

Concerns summary Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, despite the time-sensitive nature of the condition, likely contributing to death.

Concerns summary There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance on interpreting snoring, the impact of intoxication, and effective information sharing.

Concerns summary Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.

Concerns summary The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.

Concerns summary Oxygen was incorrectly administered at a care home, with staff failing to recognise appropriate emergency oxygen levels and positioning. The clinical manager, a registered nurse, lacked training in oxygen administration.

Concerns summary Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting confidentiality, prevented effective support for a distressed student.

Concerns summary Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, inadequate interpretation of radiology findings, and improper use of early warning scores for sepsis.

Concerns summary Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.

Concerns summary Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.

Concerns summary Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.

Concerns summary Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.

Concerns summary Multiple agencies demonstrated critical failures: unclear protocols for voluntary mental health patients with police, inadequate patient assessment (missing suicide inquiries, collateral history), poor inter-agency communication, and failure to record vital suicidal declarations.

Concerns summary There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.

Concerns summary Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.

Concerns summary Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.

Concerns summary Lack of clarity in procedures for arranging patient transportation led to necessary care being missed due to administrative issues.

Concerns summary The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.

Concerns summary The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing a high-risk patient's mobility.

Concerns summary The ward suffered from a lack of clear leadership, insufficient staffing, and uncoordinated patient care. Critical failures included a missing notes protocol, and no clear procedure for managing refusal of vital checks or escalating severe hyperglycaemia.

Concerns summary The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.