North London

Concerns summary A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.

Concerns summary The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.

Concerns summary The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.

Concerns summary Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.

Concerns summary Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.

Concerns summary There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and a bell.

Concerns summary A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.

Concerns summary The current PEWS scores are not aligned with research on child illness and may dangerously distract doctors from recognising seriously ill children despite low scores.

Concerns summary The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.

Concerns summary Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.

Concerns summary Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.

Concerns summary Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.

Concerns summary The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing future deaths.

Concerns summary Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.

Concerns summary Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher observation standards previously in place would likely have prevented the death.

Concerns summary There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.

Concerns summary The inability to identify appliance details after severe fire damage hinders accurate defect pattern recognition, and inconsistent information sharing among Fire & Rescue Services impedes product safety investigations.

Concerns summary The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.

Concerns summary Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.

Concerns summary All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.

Concerns summary There is no national guidance defining the role of interpreters during labour, specifically concerning their presence and responsibilities in operating theatres.

Concerns summary The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.

Concerns summary There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.

Concerns summary The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.

Concerns summary The road junction lacked adequate pedestrian safety features, including no clear view of traffic lights, no 'red man/green man' signals, and no pedestrian control buttons, making it unsafe to cross.