Inner South London

Concerns summary Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.

Concerns summary Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation may be critically needed.

Concerns summary Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical diagnostic investigations.

Concerns summary A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.

Concerns summary The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.

Concerns summary Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and insufficient information provided to ambulance services.

Concerns summary The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage to warn users of potential conflict, especially for cyclists.

Concerns summary Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health assessment information not being effectively shared or accessed.

Concerns summary Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.

Concerns summary Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of the inquest.

Concerns summary Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.

Concerns summary Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits and inconsistent glucose testing, for mental health patients. This indicates a systemic failure to implement crucial safety recommendations and ensure appropriate medical oversight.

Concerns summary Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.

Concerns summary A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.

Concerns summary The bridge lacked essential pedestrian safety measures, including central barriers and adequate lighting. This created dangerous conditions where oncoming headlights blinded drivers to pedestrians in the carriageway.

Concerns summary Organizers of an unlicensed rave failed to provide medical assistance, delayed calling emergency services, and operated in an unsafe venue with poor ventilation. Police lacked sufficient powers to intervene effectively in squatted commercial premises.

Concerns summary The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.

Concerns summary A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.

Concerns summary A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe failures in discharge planning and care coordination.

Concerns summary The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.

Concerns summary The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.

Concerns summary Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.

Concerns summary Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. Social Services also failed to maintain comprehensive contact lists and hold timely strategy meetings.