London (South)

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

Concerns summary Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons unit.

Concerns summary Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.

Concerns summary Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.

Concerns summary The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, including "ambulance technicians," largely unregulated, with insufficient checks on mentor suitability for trainees.

Concerns summary An easily accessible wall, despite meeting regulations, has been the site of multiple deaths and poses a danger, particularly to impaired individuals. Physical modifications may be necessary to prevent future fatalities.

Concerns summary Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such cases.

Concerns summary Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, forcing unsafe crossing angles and conflicts with pedestrians.