Suffolk

Concerns summary There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from informing future assessments and potentially vital support decisions.

Concerns summary Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.

Concerns summary A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.

Concerns summary A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.

Concerns summary Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.

Concerns summary The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.

Concerns summary A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.

Concerns summary Fire safety regulations for paid accommodation lack clear standards, mandatory records, and specific risk assessment guidance, leading to potential shortcuts and misunderstandings by proprietors.

Concerns summary NHS England clinicians often lack awareness of the critical distinction between hiatus hernia types, leading to insufficient vigilance for higher-risk para-oesophageal cases and hindering appropriate patient care.

Concerns summary A lack of weekend oncology support hindered safe discharge planning, and poor emergency department record management meant critical chemotherapy history was missed upon readmission, risking adverse outcomes.

Concerns summary The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.

Concerns summary The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.

Concerns summary A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes for admission, led to a denied hospitalisation.

Concerns summary The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.

Concerns summary A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.

Concerns summary NICE guidelines on post-hip fracture anti-coagulation may be outdated, potentially increasing the risk of arterial clots due to hypercoagulability after stopping VTE prophylaxis in elderly, immobile patients.

Concerns summary An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.

Concerns summary An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for emergency departments exacerbated this risk.

Concerns summary Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, and there were significant delays in accessing mental health services and medication reviews despite escalating patient distress.

Concerns summary A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules or short-notice changes, risking future adverse health outcomes.

Concerns summary Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care investigations, failing to assess the mental health impact of child removal processes or provide independent support. Funding for specialist therapy was also problematic.

Concerns summary The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.

Concerns summary Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.

Concerns summary Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.

Concerns summary A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant risk to other patients.