Inner South London

Concerns summary Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.

Concerns summary Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, potentially missing cases requiring immediate hospital transfer.

Concerns summary A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.

Concerns summary The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.

Concerns summary Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.

Concerns summary Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in emergency response.

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 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 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 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 The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.

Concerns summary The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.

Concerns summary Unblocked access points to commercial unit roofs under railway arches allow unauthorized persons to climb from the street, posing a safety risk.

Concerns summary Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.

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 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 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 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.