2015

Concerns summary A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.

Concerns summary Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.

Concerns summary Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.

Concerns summary Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs and a lack of separate lanes for cyclists.

Concerns summary The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.

Concerns summary The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.

Concerns summary Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.

Concerns summary Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.

Concerns summary The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.

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

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 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 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.