Community health care and emergency services related deaths

Concerns summary Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.

Concerns summary A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.

Concerns summary A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.

Concerns summary Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on family input, without direct verification of the correct dosage.

Concerns summary The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.

Concerns summary GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.

Concerns summary The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.

Concerns summary Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and resuscitation significantly compromised care for a patient with complex mental health needs.

Concerns summary The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, poor documentation, and a lack of processes for reviewing significant events to learn from them.

Concerns summary Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked a system for recording such information.

Concerns summary A critical misunderstanding exists between agencies regarding the urgent execution of Mental Health Act warrants, leading to ineffective inter-agency cooperation and a failure to learn from incidents, risking public safety.

Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.

Concerns summary An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.

Concerns summary Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.

Concerns summary Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's continued operation with inadequate care and record-keeping poses a significant risk of future deaths.

Concerns summary Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a less safe system.

Concerns summary Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.

Concerns summary An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.

Concerns summary Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.

Concerns summary Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.

Concerns summary Specific concerns were unavailable as the text referenced an attached sheet.

Concerns summary A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.

Concerns summary Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."

Concerns summary The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications being continued and a lack of proper rationale for prescribing.