Community health care and emergency services related deaths

Concerns summary Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.

Concerns summary The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe incidents.

Concerns summary Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.

Concerns summary The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.

Concerns summary A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.

Concerns summary Repeated misdiagnoses occurred at the hospital, despite clear GP instructions, due to systemic failures in accessing electronic patient records and slow scanning of notes.

Concerns summary A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a second opinion, highlighting a critical lack of safeguards in risk assessment.

Concerns summary Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.

Concerns summary Systemic failures in domestic abuse management included inadequate police training on risk assessment and coercive control, poor information sharing with CPS, and insufficient use of protective measures like bail and DVPNs.

Concerns summary Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary team consultation.

Concerns summary Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.

Concerns summary Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.

Concerns summary Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis and treatment.

Concerns summary Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays in arranging post-discharge care packages.

Concerns summary Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for emergency medical assistance.

Concerns summary Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.

Concerns summary An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction entries in medical records.

Concerns summary There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.

Concerns summary A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the overdose history during repeat prescription authorization, lacking critical scrutiny.

Concerns summary Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.

Concerns summary A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.

Concerns summary Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.

Concerns summary Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.

Concerns summary The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a patient's risks. Poor medical notes and long-standing local concerns about the practice were also noted.

Concerns summary Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.