Community health care and emergency services related deaths

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 Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack of escalation or specialist involvement.

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 Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.

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 The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.

Concerns summary Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical history was unavailable. This created significant risks for vulnerable patients, hindering comprehensive assessment.

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 The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that could have saved their life.

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.

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 The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.

Concerns summary There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.

Concerns summary Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed risks to patient safety.

Concerns summary Critical failures include outdated care plans, poor record-keeping and information compilation, lack of psychiatrist reviews, inconsistent risk assessment policies, and inadequate handover procedures, all contributing to a fragmented care system.