Alcohol, drug and medication related deaths

Concerns summary There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.

Concerns summary Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.

Concerns summary The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective treatment.

Concerns summary There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.

Concerns summary National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.

Concerns summary DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors or flexible appointment management.

Concerns summary Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.

Concerns summary Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus support may discourage students with addiction from seeking help.

Concerns summary Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending a deceased person's address.

Concerns summary Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.

Concerns summary The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.

Concerns summary The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.

Concerns summary A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.

Concerns summary Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.

Concerns summary Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and substance misuse, may be lost, jeopardizing vital services.

Concerns summary The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.

Concerns summary The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.

Concerns summary Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.

Concerns summary Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.

Concerns summary The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.

Concerns summary The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.

Concerns summary Hospital staff repeatedly failed to check a patient's literacy during admission and discharge, leaving her unable to read critical written instructions. This systemic failure risks patients not understanding vital care information.

Concerns summary Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare provision compared to England.

Concerns summary The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.

Concerns summary The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates risks of misuse or environmental harm.