Inner South London

Concerns summary Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.

Concerns summary There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.

Concerns summary The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm risk assessment and an absence of a comprehensive care and treatment plan for core needs.

Concerns summary Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, hindering timely and effective care.

Concerns summary Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.

Concerns summary Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.

Concerns summary The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.

Concerns summary Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety Units face significant workload pressures impacting safeguarding effectiveness.

Concerns summary The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time for staff to assess and understand the individual's needs.

Concerns summary Systemic failures across multiple agencies including police, social services, and the Child Maintenance Service led to inadequate recording, sharing, and acting upon domestic violence risks and protective orders, leaving victims vulnerable.

Concerns summary Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by capacity, not clinical need.

Concerns summary National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.

Concerns summary A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a critical antibiotic was not confirmed.

Concerns summary Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.

Concerns summary Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was ineffective safety officer monitoring, poor leadership and risk assessment during restraint, and insufficient paramedic input.

Concerns summary HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.

Concerns summary Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.

Concerns summary Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.

Concerns summary Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.

Concerns summary The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that could have saved their life.

Concerns summary Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately assess and refer individuals requiring urgent mental health support.

Concerns summary There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make appropriate specialist referrals for a deteriorating patient.

Concerns summary The provided text outlines the coroner's duty to report matters of concern but does not detail any specific safety issues or systemic failures.

Concerns summary Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.

Concerns summary Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds risk future preventable deaths.