Community health care and emergency services related deaths

Concerns summary Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall risk.

Concerns summary Healthcare staff lacked awareness of the food refusal policy and failed to conduct necessary mental capacity assessments for patients refusing food.

Concerns summary Barts Health Trust failed to investigate a patient's death under the NHS Patient Safety Framework, missing crucial learning opportunities regarding infection causes and communication with a profoundly learning disabled patient.

Concerns summary Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was inadequate, causing delays in response.

Concerns summary Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.

Concerns summary A patient with multiple choking risk factors was not referred for Speech and Language Therapy due to high intervention thresholds and long waiting lists, despite a care plan recommending observation.

Concerns summary The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient needs exceeding capacity.

Concerns summary Suboptimal staffing levels on Ward 90, caused by recruitment difficulties, increase the risk of patient falls due to insufficient dedicated nursing care.

Concerns summary Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.

Concerns summary Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.

Concerns summary Nursing staff repeatedly failed to adhere to 'nil by mouth' instructions despite clear documentation and visual cues, indicating potential underlying attitudinal issues and inadequate record-keeping practices.

Concerns summary Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.

Concerns summary Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.

Concerns summary Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the detainee adequately.

Concerns summary There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate midwife training.

Concerns summary Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.

Concerns summary There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.

Concerns summary The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential future deaths.

Concerns summary A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.

Concerns summary Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.

Concerns summary A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.

Concerns summary Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and intervention for victims.

Concerns summary Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.

Concerns summary Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.

Concerns summary There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths also show significant discrepancies.