Alcohol, drug and medication related deaths

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.

Concerns summary Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.

Concerns summary Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control issues. Additionally, medical record-keeping was poor, failing to document clinical decisions and discussions.

Concerns summary Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for mental health support was delayed by a long backlog, with referrers unaware of the service's capacity issues.

Concerns summary Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable older adolescents, missing crucial support opportunities.

Concerns summary An inexperienced practitioner made treatment decisions without senior oversight. Patients were discharged for a single missed appointment and voicemail, despite long waiting lists, without assessing their current situation or input from other agencies.

Concerns summary The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm risk assessment and an absence of a comprehensive care and treatment plan for core needs.

Concerns summary Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and Care Act re-referrals for changing accommodation are resisted.

Concerns summary The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or provide fixed overdose treatment training for doctors.

Concerns summary The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.

Concerns summary A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.

Concerns summary The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when he continued private practice. A critical lack of multi-disciplinary review, relying on the medical hierarchy, was noted given the gravity and prior similar cases.

Concerns summary Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.

Concerns summary An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of concerns. There was also a lack of follow-up for this remote prescribing.

Concerns summary There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.

Concerns summary A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without awareness of the patient's history.

Concerns summary The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Concerns summary Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of vulnerable individuals, and poor inter-agency information sharing. There was no single point of contact for complex cases and insufficient police training on domestic abuse and suicide risk.

Concerns summary The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also concerns about limited access to specialist pain clinics and underutilization of practice pharmacists for complex pain management.

Concerns summary The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.

Concerns summary National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.

Concerns summary Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.

Concerns summary Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its potential for varied abuse.

Concerns summary Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or incapacitation.