Community health care and emergency services related deaths

Concerns summary There was a lack of clinician awareness regarding PVL Staphylococcus Aureus and national guidance, compounded by poor communication between critical care and microbiology. Inadequate training on internal hospital systems also posed patient risks.

Concerns summary Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.

Concerns summary There was a fundamental failure to assess mental capacity by local authority staff, undermining discharge planning. Assumptions about responsibility between clinical and integrated care teams led to inadequate needs assessments.

Concerns summary Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways and timely lumbar puncture. No falls risk assessment despite patient confusion contributed to a fall.

Concerns summary A GP miscalculated a patient's clot and cardiovascular risk when prescribing contraception due to misinterpreting guidelines and overlooking critical information, highlighting a need for improved risk assessment.

Concerns summary The absence of a system to prescribe appropriate antibiotic forms for frail patients caused delays. The "ASK MY GP" system hindered communication, and a lack of face-to-face GP assessments delayed recognition of patient deterioration.

Concerns summary The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative care discussions.

Concerns summary The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and unclear DNACPR status.

Concerns summary The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. Similar deficient practices may pose a risk at their other operational nursing home.

Concerns summary Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.