South London

Concerns summary Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers and health providers.

Concerns summary Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.

Concerns summary Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future deaths.

Concerns summary Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency departments were identified.

Concerns summary The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.

Concerns summary A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.

Concerns summary Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities to revise safety packages.

Concerns summary Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action planning.

Concerns summary Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial information sharing between departments.

Concerns summary Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of Mental Health Act section was necessary.

Concerns summary Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns about avoidable fatalities in future cases.

Concerns summary Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.

Concerns summary Unacceptably long and increasing waiting times for CAMHS assessment and treatment, due to a severe lack of resources, pose a significant risk to young people's mental health.

Concerns summary Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic areas, compounded by no national 'risk flagging' system or out-of-hours GP access.

Concerns summary Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for mental health support was delayed by a long backlog, with referrers unaware of the service's capacity issues.

Concerns summary Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.

Concerns summary The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a significant risk.

Concerns summary Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.

Concerns summary Inadequate staffing, poor call bell response times, and a systemic failure to complete falls risk assessments for vulnerable patients compromise safety across hospital wards.

Concerns summary Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice for managing patient resistance to turning.

Concerns summary The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.

Concerns summary Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.

Concerns summary An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons learned or staff training.

Concerns summary Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, delaying crucial assessment and appropriate referral.