Community health care and emergency services related deaths

Concerns summary Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.

Concerns summary Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.

Concerns summary Following forced police entry, an occupied house was left with its main exit boarded up and the secondary exit unusable, creating a significant fire safety risk by denying residents alternative escape routes.

Concerns summary A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.

Concerns summary Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer patients to crisis teams.

Concerns summary Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage instructions, posing a significant risk.

Concerns summary Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating health.

Concerns summary Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and incomplete information. There is no specific NICE guidance for elderly femur fracture management.

Concerns summary COVID-19 restrictions significantly impacted care delivery, leading to insufficient face-to-face GP consultations and delayed mental health support, preventing early recognition of deteriorating health.

Concerns summary There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire loads arising from hoarding behavior.

Concerns summary Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation efforts.

Concerns summary Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.

Concerns summary Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises concerns about the reliability of patient information.

Concerns summary Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.

Concerns summary GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for vulnerable patients.

Concerns summary Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.

Concerns summary A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, and suffering from poor sight lines.

Concerns summary A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.

Concerns summary Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.

Concerns summary There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.

Concerns summary There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.

Concerns summary The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.

Concerns summary A lack of safety barriers between the highway and a storm drain at a road exit poses a significant risk of cyclists and vehicles falling into it.

Concerns summary The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.

Concerns summary A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.