Alcohol, drug and medication related deaths

Concerns summary Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.

Concerns summary An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.

Concerns summary Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.

Concerns summary Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers during a critical incident.

Concerns summary Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.

Concerns summary The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.

Concerns summary The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and difficulty in accurately auditing prescribing history, posing a risk of medication errors.

Concerns summary The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.

Concerns summary Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.

Concerns summary The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.

Concerns summary Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.

Concerns summary The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.

Concerns summary A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.

Concerns summary There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care frameworks, leading to fragmented support and increased risk during crises.

Concerns summary Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific alcohol misuse guidance from the Rugby Football Union for volunteer-run organizations.

Concerns summary Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding risks are prevalent.

Concerns summary Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, inadequate staff training, poor assessment protocols, and insufficient mental health support.

Concerns summary Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions for anyone falling into the water.

Concerns summary Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff lacked mandatory refresher training.

Concerns summary Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.

Concerns summary Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.

Concerns summary There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.

Concerns summary Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to monitor and prevent its sale for human consumption, risking further deaths.

Concerns summary Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also contains inaccurate medical information and lacks effective embedding methods, risking inappropriate officer responses.

Concerns summary Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to instruct carers to secure the medication, posing a safety risk.