2022

Concerns summary Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, non-emergency method to alert the paediatric team.

Concerns summary The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess for self-harm or coordinate mental health crisis intervention resources with police and health providers.

Concerns summary The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to monitor whether care plans were being met, despite clear signs of refusal for essential care.

Concerns summary Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem examinations, limiting coronial findings, learning, and parental information.

Concerns summary The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous guidelines on the "silent approach" and use of warning equipment.

Concerns summary A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both the armed forces and the family was inadequate, hindering effective risk sharing and support.

Concerns summary The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and insufficient education for medical staff and high-risk patients. There's also a lack of robust systems to capture anaphylaxis cases.

Concerns summary The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.

Concerns summary The care home failed to ensure adequate fluid intake for the resident, particularly during hot weather, and maintained poor records. A critical lack of on-site management was also identified.

Concerns summary An elderly, post-operative patient was discharged from hospital without a care package or follow-up, and subsequent GP referrals for home support were mishandled, highlighting a systemic lack of patient aftercare.

Concerns summary Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control issues. Additionally, medical record-keeping was poor, failing to document clinical decisions and discussions.

Concerns summary Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.

Concerns summary There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental health crisis. FCDO travel advice is insufficient regarding the specific consequences of detention in Dubai.

Concerns summary A significant delay in ambulance attendance likely contributed to the deceased's death, stemming from systemic capacity issues within local NHS Trusts, not solely the ambulance service.

Concerns summary Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for mental health support was delayed by a long backlog, with referrers unaware of the service's capacity issues.

Concerns summary Systemic delays in discharging medically fit patients from hospital are caused by insufficient intermediate care capacity. Discharging patients to understaffed residential homes results in patient deterioration and re-admissions, exacerbating hospital pressures.

Concerns summary Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.

Concerns summary There was a critical failure in emergency response, with ambulance services delaying attendance for a gravely ill patient deemed low priority despite severe pain. Out-of-hours GP services also failed to provide adequate advice, pain relief, or expedite hospital admission.

Concerns summary There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.

Concerns summary There was a critical 12-hour delay in reviewing a patient with melaena, and anti-coagulation therapy was not withheld. The hospital's late disclosure of its internal review hampered the inquest and learning process.

Concerns summary Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.

Concerns summary Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled to identify critical haemoglobin test results amidst high volumes, highlighting a need for better prompts and education.

Concerns summary Critical ambulance delays are common due to high demand and staffing shortages. Additionally, weekend availability of cardiac tests at district general hospitals delays urgent surgery, contradicting best practice.

Concerns summary Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack of awareness for neutropenic sepsis guidance also led to missed red flags and delayed critical treatment.