Community health care and emergency services related deaths

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 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 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 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.

Concerns summary Strict adherence to national cervical screening guidance led to delayed smear tests for a vulnerable patient, with the guidance potentially excluding a cohort of women and delaying crucial cancer diagnosis.

Concerns summary Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing risk of future deaths.

Concerns summary There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission despite family preferences for home care.

Concerns summary GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a lack of appropriate secondary care referral.

Concerns summary There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.

Concerns summary An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical communication gaps between emergency services.

Concerns summary Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.

Concerns summary The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.

Concerns summary Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.

Concerns summary A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.

Concerns summary Malnutrition and declining frailty were not adequately investigated by primary and secondary care, making the patient unsuitable for lifesaving treatment, compounded by a lack of internal investigations.

Concerns summary The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.

Concerns summary Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.

Concerns summary GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.