Community health care and emergency services related deaths

Concerns summary Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of preventable deaths.

Concerns summary Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.

Concerns summary The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.

Concerns summary Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.

Concerns summary Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper policy, training, or consistent application.

Concerns summary Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.

Concerns summary The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.

Concerns summary GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded by deficient CCG guidance on dosage.

Concerns summary Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.

Concerns summary A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for their cultural diet and eating practices.

Concerns summary There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally required annual Care Act reviews due to resource constraints.

Concerns summary Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.

Concerns summary The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.

Concerns summary Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused distress with unbeneficial procedures, including End of Life Care decisions without proper assessment.

Concerns summary The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.

Concerns summary Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.

Concerns summary Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.

Concerns summary A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.

Concerns summary The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.

Concerns summary Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked a system for recording such information.

Concerns summary A critical misunderstanding exists between agencies regarding the urgent execution of Mental Health Act warrants, leading to ineffective inter-agency cooperation and a failure to learn from incidents, risking public safety.

Concerns summary An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.

Concerns summary Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.

Concerns summary An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.

Concerns summary Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.