Norfolk

Concerns summary Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.

Concerns summary Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's death.

Concerns summary Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk individual. Key external health providers were also not contacted for assistance.

Concerns summary Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, and infrequent safety briefings.

Concerns summary Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.

Concerns summary The death was caused by liver damage from parenteral nutrition extravasation, likely due to a low-lying umbilical venous catheter, highlighting risks associated with currently acceptable UVC placement practices.

Concerns summary Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.

Concerns summary A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic flaw in patient transfer procedures between Trusts.

Concerns summary There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.

Concerns summary Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.

Concerns summary Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.

Concerns summary A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.

Concerns summary Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.

Concerns summary Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.

Concerns summary There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.

Concerns summary Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.

Concerns summary Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.

Concerns summary Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.

Concerns summary Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.

Concerns summary The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and unclear DNACPR status.