Alcohol, drug and medication related deaths

Concerns summary Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.

Concerns summary Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.

Concerns summary Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without GP notification.

Concerns summary Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.

Concerns summary Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.

Concerns summary Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.

Concerns summary The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.

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 There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.

Concerns summary The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review medication side-effect monitoring protocols.

Concerns summary Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.

Concerns summary The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in implementing a traffic management order and building a new crossing, poses ongoing risks.

Concerns summary Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an urgent need for a new controlled crossing and neglected funding applications.

Concerns summary There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe use.

Concerns summary West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.

Concerns summary Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.

Concerns summary There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.

Concerns summary Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.

Concerns summary The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.

Concerns summary The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.

Concerns summary Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not adequately understood or managed.

Concerns summary The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.

Concerns summary A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.

Concerns summary Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist other agency support or inquire about her location and potential assistance.

Concerns summary The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction amounts and frequency, poses a significant risk.