Community health care and emergency services related deaths

Concerns summary Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational age babies.

Concerns summary There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.

Concerns summary A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, compounded by inadequate staff training.

Concerns summary The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, and self-harm incidents lacked debriefs to inform future risk assessments.

Concerns summary Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.

Concerns summary Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.

Concerns summary Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also hindered family advocacy.

Concerns summary Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure areas and falls, were absent. Staff training and escalation procedures for deteriorating patients were inadequate, leading to undocumented pressure ulcers.

Concerns summary The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell functionality and specialist advice delays. The incident's "moderate" harm grading was not revisited despite its contribution to the patient's death.

Concerns summary A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about insufficient urgency in training. Additionally, the placenta was not retained, hindering vital examination for learning.

Concerns summary There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.

Concerns summary There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.

Concerns summary The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.

Concerns summary The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.

Concerns summary Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis and treatment.

Concerns summary High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.

Concerns summary The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.

Concerns summary GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.

Concerns summary Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.

Concerns summary The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active patients, even for short treatment courses.

Concerns summary Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training for medical professionals contributed to a preventable death.

Concerns summary Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to difficulties in charting wound progress and providing correct care.

Concerns summary A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.

Concerns summary Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health Professional, increasing risk of self-harm or suicide.

Concerns summary The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.