Norfolk

Concerns summary A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.

Concerns summary The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and assisted technology for patient falls prevention are significantly delayed.

Concerns summary The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.

Concerns summary An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.

Concerns summary Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.

Concerns summary Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.

Concerns summary Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor record-keeping and an inadequate system for junior doctor case review by seniors were identified.

Concerns summary Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.

Concerns summary Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented proper escalation of patient care.

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 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 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 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 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 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.