2015

Concerns summary Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.

Concerns summary Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.

Concerns summary The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.

Concerns summary Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.

Concerns summary Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.

Concerns summary Delays of up to 24 hours in 'writing up' medical consultations risk important information being unavailable or misinterpreted, potentially harming patients.

Concerns summary A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to prevent recurrence in line with building regulations.

Concerns summary Insufficient resources were available for the London Ambulance Service to meet demand on the day of the incident.

Concerns summary Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating significant fall risks.

Concerns summary A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite its location next to a main road.

Concerns summary Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.

Concerns summary General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.

Concerns summary Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.

Concerns summary Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.

Concerns summary Assessing fitness to travel for direct repatriation requires medical expertise beyond a paramedic, and independent medical assessment should be considered in such cases.

Concerns summary No attempt was made to obtain historical input or information from private clinicians when the patient reverted to NHS mental health care, missing potentially helpful treatment guidance.

Concerns summary An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.

Concerns summary The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a significant risk of future deaths.

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 Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.

Concerns summary Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.

Concerns summary A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.

Concerns summary The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road safety hazard.

Concerns summary PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for GP collaboration or for communicating patient physical conditions to GPs.