Community health care and emergency services related deaths

Concerns summary Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of injury or death.

Concerns summary Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.

Concerns summary There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked crucial evidence, and did not consider potential third-party involvement, compromising the investigation.

Concerns summary The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike individuals, highlighting a gap in preventing harm to trespassers on the line.

Concerns summary There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment during the hospital triage process.

Concerns summary The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.

Concerns summary The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients meant out-of-hours services lacked full access to critical medical history.

Concerns summary Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.

Concerns summary Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.

Concerns summary Concerns were raised regarding the ambulance service's policy and training around the Mental Capacity Act, specifically concerning the non-use of force or restraint for patients refusing transport.

Concerns summary PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for GP collaboration or for communicating patient physical conditions to GPs.

Concerns summary Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.

Concerns summary A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to highlight uncollected prescriptions, especially for dependent patients.

Concerns summary There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.

Concerns summary Ambulance control failed to accurately locate a severe incident due to inaccurate GPS and a call handler's lack of local knowledge. Inadequate cross-boundary systems prevented effective call transfer or dispatch of a nearby ambulance, causing critical delays.

Concerns summary The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients in the community or transfer them to hospital.

Concerns summary A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that standard electrical testing may miss. The Fire and Rescue Service needs to alert the community.

Concerns summary Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a broken leg being advised to take a taxi to the hospital. Systemic issues were exacerbated by A&E delays and bed blocking.

Concerns summary The dispatch team lacked immediate visibility of incoming incidents, hindering timely action. Also, the landowner of a high-risk river stretch should consider providing vandal-proof life buoy stations.

Concerns summary A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on crisis team service limitations.

Concerns summary Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.

Concerns summary Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.

Concerns summary The report highlights a need for consideration of further legislation to address a critical point, indicating a gap in existing legal frameworks relevant to preventing future deaths.

Concerns summary A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.