Community health care and emergency services related deaths

Concerns summary The system for providing antibiotics and steroids to COPD patients on request lacks explicit advice for them to seek medical attention if their condition does not improve within a specified period.

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

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 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 Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns due to insufficient interaction time with vulnerable service users.

Concerns summary A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical records and computer system, leading to a lack of awareness and follow-up.

Concerns summary Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental health services are also unsafely raising referral thresholds.

Concerns summary Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, hindering investigation.

Concerns summary Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.

Concerns summary The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for medical assistance.

Concerns summary A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.

Concerns summary There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.

Concerns summary Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of existing users.

Concerns summary There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.

Concerns summary Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.

Concerns summary Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, which was also not placed under surveillance, unlike her abdominal aneurysm.

Concerns summary Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.

Concerns summary The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.

Concerns summary The emergency services lacked an effective system for managing multiple calls, prioritising resources, and mobilising appropriate appliances, compounded by inadequate staff training and difficult-to-use systems.

Concerns summary A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient with severe dementia led to a two-week delay in diagnosing a fractured hip.

Concerns On the 22/12/2016 opened an inquest into the death of Keith William Rushton who, at the date of his death was 78 years old. The inquest was resumed and concluded on 31/8/2016. Ifound that the cause...

Concerns summary A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.