Alcohol, drug and medication related deaths

Concerns summary Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and posed a safety risk.

Concerns summary Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible across different sites.

Concerns summary Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals released at short notice.

Concerns summary Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.

Concerns summary Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.

Concerns summary A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside a lack of risk assessment and follow-up for deteriorating mental health, created significant safety risks.

Concerns summary A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.

Concerns summary The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring parents to manage complex detoxification at home.

Concerns summary The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.

Concerns summary Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient capacity leading to unaddressed obvious vulnerability.

Concerns summary The Rugby Football League's Welfare Policy allows clubs outside the Super League to relax illicit drug education and conduct rules, risking young players who need consistent guidance due to their immaturity.

Concerns summary Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows to open fully and posing a significant fall risk.

Concerns summary Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.

Concerns summary GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future deaths.

Concerns summary Clinicians and practitioners involved in mental health inpatient discharge lack adequate training in the discharge process, particularly concerning complex issues arising from out-of-area admissions.

Concerns summary Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, as a failure to refer for cancellation contributed to despair and death.

Concerns summary Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of positional asphyxia in detainees. There's also no mandatory refresher training for constant observations.

Concerns summary A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted works.

Concerns summary Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.

Concerns summary Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.

Concerns summary Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.

Concerns summary Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.

Concerns summary There was a serious failure to manage the deceased's intoxication and unrousable state in prison, with medical help not sought despite clear signs. Critical opportunities for escalation and appropriate care were missed.

Concerns summary Critical patient information, including self-harm risk and medication details, was not communicated to carers. There was also a failure to standardize the understanding of medical abbreviations among staff, impacting patient safety.

Concerns summary The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to hospital handover delays. The number of funded ambulances appeared insufficient.