Inner North London

Concerns summary There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.

Concerns summary A vulnerable person struggled to contact their social worker for weeks due to unavailable contact channels, including an unattended crisis line. This highlights inadequate support arrangements for those in need.

Concerns summary A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.

Concerns summary A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.

Concerns summary Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to recognise and respond to cardiac arrest.

Concerns summary Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.

Concerns summary Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.

Concerns summary Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.

Concerns summary Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.

Concerns summary School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.

Concerns summary Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of safety barriers or window restrictors created a significant fall risk in housing properties.

Concerns summary A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising against proper record-keeping and a general lack of trust cooperation with the inquest.

Concerns summary An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.

Concerns summary CPAP machine alarms do not distinguish between minor leaks and critical oxygen cessation, causing confusion and delays in responding to serious patient deterioration, especially with multiple alarms.

Concerns summary Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate systemic failures in patient care and information management.

Concerns summary The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.

Concerns summary There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire loads arising from hoarding behavior.

Concerns summary A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.

Concerns summary A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect care being provided by district nurses.

Concerns summary Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.

Concerns summary Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care coordinator, hindering comprehensive mental health care.

Concerns summary The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.

Concerns summary There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.

Concerns summary The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.

Concerns summary A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.