Community health care and emergency services related deaths

Concerns summary Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable to challenge decisions, impacting patient safety.

Concerns summary Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.

Concerns summary Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.

Concerns summary Persistent paramedic vacancies continue to cause concerns regarding the timely despatch and arrival of ambulances, posing a risk of future deaths due to delayed emergency response.

Concerns summary Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from unprogressed requests and incorrect referral classifications.

Concerns summary Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to prevent serious self-harm.

Concerns summary Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not clearly implemented.

Concerns summary A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.

Concerns summary There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.

Concerns summary Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet audit targets.

Concerns summary Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication protocols between staff and ambulance services were inconsistent.

Concerns summary A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the encounter.

Concerns summary Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.

Concerns summary GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.

Concerns summary The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing resources and delaying emergency response.

Concerns summary A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the doctor's fitness to practice and highlighting wider public safety implications of such practices.

Concerns summary Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.

Concerns summary Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.

Concerns summary Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks in community health care for vulnerable individuals.

Concerns summary Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users do not respond or cannot be found.

Concerns summary Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.

Concerns summary Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.

Concerns summary The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The family also faced barriers in sharing critical information with professionals.

Concerns summary Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking severe complications and highlighting the need for a review of head injury recognition protocols.

Concerns summary An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.