North East Kent

Concerns summary There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures have created a critical shortage of beds, leading to inappropriate care settings or discharge without adequate support.

Concerns summary A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a lack of resilience and capacity in mental health services.

Concerns summary A critical failure to provide a case manager or key worker for autistic young people, as per NICE guidance, limits access to support services and prevents navigation of care pathways.

Concerns summary “Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to involve carers, patients could be discharged without essential support.

Concerns summary Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.

Concerns summary A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.

Concerns summary Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns summary There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.

Concerns summary The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and the patient being discharged to unsafe living conditions.

Concerns summary A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between local authorities.

Concerns summary Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.

Concerns summary The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.

Concerns summary A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.

Concerns summary A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.

Concerns summary Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration risks.

Concerns summary Multiple deaths on a ward were linked to inadequate or unenforced falls risk assessments. Specific to this case, the assessment was perfunctory, bed rails were misused, and no protective measures were implemented post-fall.

Concerns summary No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.

Concerns summary Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.

Concerns summary Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.

Concerns summary There was a lack of senior consultant review, inadequate daily review of test results, and inconsistent medical records, leading to a lack of clarity in patient care and planning.

Concerns summary Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's condition. These delays significantly reduced her chances of survival.

Concerns summary A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.

Concerns summary The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.