Community health care and emergency services related deaths

Concerns summary Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.

Concerns summary The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.

Concerns summary A local authority failed to act on an urgent GP referral for a patient assessment, leading to a significant one-week delay before a social worker visit.

Concerns summary Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent risks to patient care continuity.

Concerns summary Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, and procedural adherence regarding care plans and risk management.

Concerns summary Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.

Concerns summary A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.

Concerns summary The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.

Concerns summary The RSSB Rule Book's provisions for stopping trains are insufficient, prioritizing potential train damage over human life. Even cautioned trains can strike individuals, highlighting a gap in preventing harm to trespassers on the line.

Concerns summary Concerns were raised regarding the ambulance service's policy and training around the Mental Capacity Act, specifically concerning the non-use of force or restraint for patients refusing transport.

Concerns summary Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.

Concerns summary There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.

Concerns summary Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.

Concerns summary A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.

Concerns summary The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.

Concerns summary Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.

Concerns summary The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.

Concerns summary Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.

Concerns summary National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.

Concerns summary The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing critical delays in treatment.

Concerns summary Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent treatment.

Concerns summary Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with incomplete address information and inadequate communication protocols with BT. Subsequent investigations and revised protocols were also insufficient and poorly implemented.

Concerns summary Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.

Concerns summary A lack of training on the correct dosage and morphine equivalent of fentanyl patches led to an erroneous prescription, contributing to the patient's death through respiratory depression.