Inner South London

Concerns summary Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold natural waters, highlighting a systemic risk of drowning without curriculum changes.

Concerns summary Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The hospital also failed to contact family/friends despite consent, and the community team did not proactively seek discharge information.

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 A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like necrotising fasciitis.

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 system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol liaison nurse post-discharge.

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 A lack of awareness regarding the safety-critical role and vulnerability of ladder spigots poses significant health and safety risks due to potential inadvertent shearing.

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 Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a blocked endotracheal tube, compromising patient care.

Concerns summary This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists are insufficient, and no standardized risk classification system for swimming is in place.

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 A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.

Concerns summary A critical gap exists in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither district nurses nor agency carers provide night visits.

Concerns summary An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA insertion.

Concerns summary Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on the platform for an extended period at a 24-hour staffed station.

Concerns summary Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.

Concerns summary Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with symptoms that are not well known.

Concerns summary Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.

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.