Community health care and emergency services related deaths

Concerns summary Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.

Concerns summary A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect care being provided by district nurses.

Concerns summary A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to fall between existing care criteria.

Concerns summary A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.

Concerns summary Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk of critical information loss.

Concerns summary Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear multi-agency strategy for complex cases involving trauma and alcohol misuse.

Concerns summary A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without appropriate care.

Concerns summary Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also no escalation process for medication refusal, exacerbated by a national bed shortage.

Concerns summary A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.

Concerns summary National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.

Concerns summary A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.

Concerns summary The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.

Concerns summary Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.

Concerns summary The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform the DVLA.

Concerns summary National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.

Concerns summary The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.

Concerns summary The landlord rented out a non-compliant cellar flat, raising concerns about similar hazards, including inadequate smoke detection and escape routes, in other properties. There is no ongoing duty for landlords to check smoke alarm effectiveness.

Concerns summary Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.

Concerns summary A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a risk of further missed appointments.

Concerns summary Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.

Concerns summary GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked national guidance on recognising and escalating dehydration risks.

Concerns summary NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. The call was then closed due to an incorrect number, missing a crucial opportunity for care.

Concerns summary The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.

Concerns summary Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.

Concerns summary Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.