2021

Concerns summary Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.

Concerns summary A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.

Concerns summary The provided text indicates general concerns exist that risk future deaths, but does not detail the specific issues or systemic failures identified by the coroner.

Concerns summary Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and a lack of follow-up systems for referrals hindered effective patient care and risk identification.

Concerns summary Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.

Concerns summary Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.

Concerns summary Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing platforms risk over-prescription, drug interactions, and patient harm.

Concerns summary Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.

Concerns summary Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.

Concerns summary A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising against proper record-keeping and a general lack of trust cooperation with the inquest.

Concerns summary Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit trails for communication.

Concerns summary The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.

Concerns summary The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.

Concerns summary The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.

Concerns summary Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.

Concerns summary The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's denial of suicidal intent. The Trust's investigation was inaccurate and inadequate.

Concerns summary The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior management showed a culture of obfuscation.

Concerns summary CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting systemic failures in equipment design and training compliance.

Concerns summary Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.

Concerns summary The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.

Concerns summary Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.

Concerns summary Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely home suitability assessments for vulnerable residents.

Concerns summary An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.

Concerns summary An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar trailers remain in use without these critical safety features, posing a risk of future accidents.

Concerns summary Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.