2017

Concerns summary Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making based on incomplete accident statistics that omitted overall incidents and near misses.

Concerns summary The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management and potential hospitalisation.

Concerns summary The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.

Concerns summary A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.

Concerns summary There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation lacking detail on clinical decision-making.

Concerns summary The provided concerns text for this report does not detail specific safety issues or systemic failures related to the deceased's care at Carlton House Rest Home.

Concerns summary Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed line for both adults and children.

Concerns summary A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.

Concerns summary Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not clearly implemented.

Concerns summary Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and concerns over 'Hospital at Night' co-ordinators' qualifications for medical prioritisation.

Concerns summary A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.

Concerns summary A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.

Concerns summary Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.

Concerns summary Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.

Concerns summary Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The hospital also failed to contact family/friends despite consent, and the community team did not proactively seek discharge information.

Concerns summary The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.

Concerns summary The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.

Concerns summary Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear instructions for these technologies.

Concerns summary The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared with relevant staff, indicating a failure to learn lessons.

Concerns summary The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to implement cast care plans, monitor for infection, or train staff.

Concerns summary Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.

Concerns summary The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.

Concerns summary The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.

Concerns summary There was a critical failure to assign a single person overall responsibility for the patient, with no new Care Co-Ordinator appointed. A recommendation for all patients to have a lead professional was marked complete but not implemented.

Concerns summary The provided text only states the coroner's statutory duty to report concerns without detailing specific issues identified.