Inner North London

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 Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and harmful content.

Concerns summary Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.

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.

Concerns summary Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.

Concerns summary Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the patient's deterioration being unrecognised.

Concerns summary A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for hours after a fall.

Concerns summary Systemic failures included misinterpretation of CT scans, staff unawareness of patient spinal conditions and equipment features, incomplete fall assessments, and unrecorded adverse reactions to procedures.

Concerns summary A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.

Concerns summary Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.

Concerns summary There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.