Community health care and emergency services related deaths

Concerns summary Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures fail to meet current guidance.

Concerns summary GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.

Concerns summary Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear evidence of deteriorating capacity.

Concerns summary Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.

Concerns summary The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation of patient safety incidents.

Concerns summary There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.

Concerns summary A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.

Concerns summary The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.

Concerns summary There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.

Concerns summary The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.

Concerns summary Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity for unwise decisions.

Concerns summary An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.

Concerns summary Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.

Concerns summary Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check for a vulnerable patient.

Concerns summary A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.

Concerns summary A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.

Concerns summary There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral information.

Concerns summary A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.

Concerns summary Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.

Concerns summary There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge from mental health services, indicating staff lacked understanding of robust risk assessment and safety planning.

Concerns summary Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health deterioration and inadequate living conditions.

Concerns summary Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, led to significant delays in critical medical assessment and treatment.

Concerns summary Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.

Concerns summary Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.

Concerns summary A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.