Inner South London

Concerns summary Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.

Concerns summary Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.

Concerns summary There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell disease, particularly concerning routine GI protection.

Concerns summary Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.

Concerns summary Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.

Concerns summary Inadequate staff training on IV medication administration speed and a systemic failure to document early cessation of IV infusions pose a risk to patient safety.

Concerns summary The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, with no clear rationale from the GP for its prescription.

Concerns summary The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.

Concerns summary Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.

Concerns summary An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed to appreciate illness severity due to inadequate training.

Concerns summary Midwives failed to timely escalate abnormal CTG results due to misapplication of guidelines and inadequate training. Concerns also arose about CTG machines potentially misinterpreting maternal heart rate as fetal heart rate.

Concerns summary Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's vulnerability and anxiety. This was exacerbated by poor communication and inconsistent ACCT reviews.

Concerns summary A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.

Concerns summary The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.

Concerns summary Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.

Concerns summary Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal and infant deaths.

Concerns summary The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.

Concerns summary Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before responding to emergency calls.