Inner North London

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 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.

Concerns summary Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.

Concerns summary There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in delivery suites hinders contemporaneous observation recording.

Concerns summary Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed to the risk.

Concerns summary There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.

Concerns summary The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in implementing a traffic management order and building a new crossing, poses ongoing risks.

Concerns summary GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded by deficient CCG guidance on dosage.

Concerns summary Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.

Concerns summary The university fails to effectively utilize mental health disclosures, relying on email invitations for support that many students do not respond to, and withholding vital information from tutors due to data protection.

Concerns summary Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.

Concerns summary Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.

Concerns summary Network Rail failed to inspect a broken fence for over two years due to inadequate inspections, flawed dual-submission reporting, and an insufficient internal investigation into systemic failures.

Concerns summary A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge from the emergency department for intending to jump, missing a critical intervention opportunity.

Concerns summary A lack of process for clinicians to alert DWP about vulnerable individuals receiving large funds, particularly those without capacity, puts them at high risk of illicit substance misuse.

Concerns summary Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.

Concerns summary The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.

Concerns summary A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.

Concerns summary A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of collisions.

Concerns summary The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to significant delays in hospital admission.

Concerns summary A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.

Concerns summary Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.