Inner West London

Concerns summary Online forums encourage suicide by providing methods without age restrictions or help signposting, and harmful content is not effectively removed. Lethal products are also easily purchased via international online retailers and delivered to the UK without effective border controls.

Concerns summary Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.

Concerns summary The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.

Concerns summary Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.

Concerns summary There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for vulnerable individuals.

Concerns summary Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and inconsistent safety pressure guidelines.

Concerns summary Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.

Concerns summary A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.

Concerns summary Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing risk of further fatalities.

Concerns summary A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation techniques for individuals experiencing psychotic episodes. The officer's training was described as a "patchwork" over many years.

Concerns summary Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of bag searches during hospital transfers, contributing to her death by overdose.

Concerns summary The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.

Concerns summary The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge were significantly delayed.

Concerns summary The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.

Concerns summary There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.

Concerns summary Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no registered landlord scheme or enforcement powers.

Concerns summary The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific coroner's concerns regarding systemic failures or safety issues for future prevention.

Concerns summary The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.

Concerns summary The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.

Concerns summary Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.

Concerns summary Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus support may discourage students with addiction from seeking help.

Concerns summary Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.

Concerns summary Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.

Concerns summary The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing to fatal injuries from uncapped poles.

Concerns summary A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.