2024

Concerns summary The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.

Concerns summary A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.

Concerns summary There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.

Concerns summary Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.

Concerns summary Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.

Concerns summary The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.

Concerns summary An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.

Concerns summary Concerns exist regarding the expertise and frequency of PAO surgeries, as many surgeons perform very few procedures annually without adequate oversight or recognition of the procedure's specialized nature.

Concerns summary A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.

Concerns summary There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.

Concerns summary The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment training.

Concerns summary In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.

Concerns summary Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.

Concerns summary A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.

Concerns summary Overwhelming demand on the Emergency Department led to deviations from triage protocols, delayed medical record keeping, and a reduced ability to identify serious conditions presenting atypically.

Concerns summary Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.

Concerns summary Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety from these systemic failures.

Concerns summary Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.

Concerns summary Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.

Concerns summary The hospital's lack of a full suite of cardiac diagnostic imaging equipment, specifically CT or MR angiograms, causes diagnostic delays and necessitates risky patient transfers.

Concerns summary A hard-to-see, locked, matt black steel barrier on a legitimate road poses a serious collision risk for cyclists and emergency vehicles, especially at dusk or in the dark.

Concerns summary Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.

Concerns summary Incomplete medical record documentation by junior doctors and a surgeon's failure to fully inform parents about treatment options hindered truly informed consent for surgery.

Concerns summary Deficiencies included unrecorded critical symptoms, poor clinician knowledge of the Acute Abdominal Pain Pathway, a flawed Serious Incident process, and a lack of clear self-discharge procedures.