Inner North London

Concerns summary A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical risk has been addressed.

Concerns summary Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety in critical situations.

Concerns summary Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the procedure's specialized nature.

Concerns summary Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.

Concerns summary Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was no feedback loop to clinicians, leaving the family without answers or safety guidance.

Concerns summary A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.

Concerns summary Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion of toxic products.

Concerns summary A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.

Concerns summary The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to critical safety protocols despite training and previous PFD reports.

Concerns summary Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.

Concerns summary A lack of clear protocols for escalating deteriorating patients and significant communication failures among clinicians led to delayed critical assessments. Misunderstandings regarding scan ordering and poor record-keeping also contributed.

Concerns summary A reported broken wrist alarm was not repaired, carers failed to act or report the fault, lacked training on alarm testing, and there was no clear system for fault reporting between agencies.

Concerns summary Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up checks and no demonstrable learning or procedural changes post-incident.

Concerns summary Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.

Concerns summary An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.

Concerns summary The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of harm.

Concerns summary Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.

Concerns summary Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address the known risk of students falling from windows.

Concerns summary A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. This poses a significant widespread risk to patients.

Concerns summary Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.

Concerns summary Frequent public access to railway tracks is facilitated by low walls, ineffective safety measures, and street furniture, posing significant risks, including to vulnerable individuals and children.

Concerns summary A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding the need for endoscopy after negative initial imaging.

Concerns summary Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.

Concerns summary There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, to a person on a block of flats roof.

Concerns summary Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.