2024

Concerns summary The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.

Concerns summary Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of a digital alert system.

Concerns summary The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.

Concerns summary The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling them to hide disqualifying conditions and pose a road risk.

Concerns summary There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries in collisions due to their vulnerability on the road.

Concerns summary Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access to healthcare support compared to those in custody.

Concerns summary Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.

Concerns summary A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed camera safety scheme.

Concerns summary The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with a lack of internal incident review.

Concerns summary The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.

Concerns summary Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and increased risk of death.

Concerns summary A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in fragmented patient care.

Concerns summary HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours clinical mental health support, leading to inadequate crisis management.

Concerns summary There was a critical lack of availability of essential medical equipment and adrenaline, which severely compromised the ability to provide emergency care.

Concerns summary The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in ensuring resident safety.

Concerns summary Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and detecting criminal financial enterprises.

Concerns summary Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed PFD reports.

Concerns summary The hospital's standard operating procedure for radiographers lacked provisions for escalating care or initiating urgent arrest calls when patients showed clear signs of imminent danger.

Concerns summary The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care and risk assessment.

Concerns summary A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary or safety netting advice for a vulnerable patient.

Concerns summary Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service gaps for high-risk individuals.

Concerns summary Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and exacerbated mental health conditions.

Concerns summary Fragmented medical record systems across hospital teams resulted in a critical multi-disciplinary team decision being overlooked, with current interim solutions still vulnerable to human error.

Concerns summary Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed to the patient's death.

Concerns summary Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies in covert bleeding.