2019

Concerns summary Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by an unavailable ICU outreach team and poor fluid chart completion.

Concerns summary Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.

Concerns summary Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.

Concerns summary Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan further compromised patient safety.

Concerns summary An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.

Concerns summary The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.

Concerns summary The provided text is incomplete and does not detail any specific concerns regarding future deaths.