2022

Concerns summary Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private ambulance was dispatched due to miscategorization, leading to further delays.

Concerns summary A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.

Concerns summary There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.

Concerns summary Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.

Concerns summary Mental health deterioration was overlooked due to poorly resourced older age psychiatric teams, inadequate staff training for residential settings, and significant delays in re-accessing services. Mental health concerns are often neglected at the end of life.

Concerns summary Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.

Concerns summary The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, poor crossing design, traffic speed, and insufficient signage.

Concerns summary The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.

Concerns summary The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.

Concerns summary Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.

Concerns summary Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

Concerns summary Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.

Concerns On 1 stApril 2021 this Court commenced an investigation into the death of Elizabeth Margaret Mills age 71 years. The investigation concluded at the end of the inquest held on the 12 th November 2021...

Concerns summary Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible improvements.

Concerns summary Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to ensure x-rays are completed when overlooked by staff, risking missed diagnoses.

Concerns summary A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety protocol.

Concerns summary The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.

Concerns summary The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.

Concerns summary University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS liaison, and adequate systems to ensure student safety after distress.

Concerns summary An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's Trust's lack of transparency, scene preservation, and proper investigation exacerbated the issues.

Concerns summary Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information sharing between multiple care agencies for a high-risk patient.

Concerns summary A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, exacerbated by a 50mph speed limit on the main road, risking collisions.

Concerns summary Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.

Concerns summary Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis and treatment.

Concerns summary A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.