Poor health and social care integration
167 items
2 sources
Lack of a fundamental shift towards collaborative, integrated system-wide change in health and social care.
Cross-Source Insight
Poor health and social care integration has been flagged across 2 independent accountability sources:
22 inquiry recs
145 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (22)
BRIS-177 — NSF must provide strategic guidance for integrating children's healthcare services
Recommendation: There must be much greater integration of primary, community, acute and specialist healthcare for children. The NSF should include strategic guidance to health authorities and trusts so that services in the future are better integrated and organised around the needs …
Unknown
BRIS-22 — Fund voluntary organisations meeting NHS standards for patient and carer support
Recommendation: Voluntary organisations which provide care and support to patients and carers in the NHS (such as through telephone helplines, the provision of information and the organisation of self-help groups) play a very important role. Groups which meet the appropriate standards …
Unknown
BRIS-3 — Adopt patient-professional partnership model across all NHS healthcare settings
Recommendation: The notion of partnership between the healthcare professional and the patient, whereby the patient and the professional meet as equals with different expertise, must be adopted by healthcare professionals in all parts of the NHS, including healthcare professionals in hospitals.
Unknown
BRIS-32 — Promote collaboration among patient advocacy services for seamless information and support
Recommendation: So as to provide for patients an effective, efficient and seamless information and advocacy service, consideration should be given to how the various patient advocacy and liaison services in a given geographical area could most effectively collaborate, including in relation …
Unknown
BRIS-61 — Implement joint inter-professional courses in healthcare professional education and training
Recommendation: The education, training and Continuing Professional Development (CPD) of all healthcare professionals should include joint courses between the professions.
Unknown
BRIS-62 — Increase opportunities for multi-professional teams to learn and train together
Recommendation: There should be more opportunities than at present for multi-professional teams to learn, train and develop together.
Unknown
BRIS-64 — Create shadowing opportunities for managers and clinicians to understand roles
Recommendation: Greater opportunities should be created for managers and clinicians to ‘shadow’ one another for short periods to learn about their respective roles and work pressures.
Unknown
BRIS-67 — Focus NHS leadership investment on joint, multi-professional training for all staff
Recommendation: The NHS’s investment in developing and funding programmes in leadership skills should be focused on supporting joint education and multi-professional training, open to nurses, doctors, managers and other healthcare professionals.
Unknown
HIA-3 — Commissioner for Survivors of Institutional Childhood Abuse (COSICA)
Recommendation: We therefore recommend that a designated person should act as an advocate for such children, and should be responsible for ensuring the co-ordination and availability of services, and identifying suitable means whereby such services can be made available to those …
Gov response: No formal government response published.
Accepted
Delivered
HIA-8 — Specialist Care and Assistance Facilities
Recommendation: Sufficient funds should be made available by government on a ring-fenced basis for a fixed period of ten years, subject to a review after five years, to establish dedicated specialist facilities in Belfast, Derry and, if necessary, at other suitable …
Gov response: No formal government response published.
Accepted
No update 2+ yrs
IBI-10a(iv) — Thalassaemia Society Support
Recommendation: Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
Gov response: UK Government NHS England has successfully established a comprehensive programme of work to prioritise reduction of clinical risk, increase support and care in the community, digitise care plans and step up prevention activities following their …
Accepted in Part
In progress
IBI-4e — Cross-Administration Patient Safety Coordination
Recommendation: Coordination of patient records with devolved governments: Consideration should be given by the national healthcare administrations in England, Scotland, Wales and Northern Ireland, to further coordination of their approaches particularly to ensure that patterns of harm, or trends, are identified …
Gov response: NHS England operates the Learn From Patient Safety Events service, analysing approximately 3 million incidents annually. Scotland requires Health Boards to notify Healthcare Improvement Scotland of significant adverse events. Coordination mechanisms continue developing across the …
Accepted
In progress
IBI-9d — Haemophilia Centre Resources
Recommendation: The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they …
Gov response: UK Government Recommendation 9d: The need to develop and strengthen multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders to improve patient care and support standardisation is supported by …
Accepted
In progress
IR2-16 — Central Delivery with Devolved Support
Recommendation: I recommend that the compensation scheme should be delivered by one central body, appropriately resourced and staffed. Current support schemes should however continue to be provided as at present by schemes local to each nation.
Gov response: In line with recommendations 14 and 16 of the Second Interim Report, IBCA has been established to deliver the Infected Blood Compensation Scheme and financial compensation to victims of infected blood on a UK-wide basis. …
Accepted
Delivered
IHRD-49 — Multi-Trust Mortality Meeting Engagement
Recommendation: Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with …
Gov response: Video conferencing facilities provided for multi-Trust mortality meetings.
Accepted
Delivered
F234 — Cooperation with the Care Quality Commission
Recommendation: Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to minimise the time taken to resolve issues and maximise the …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F235 — Joint proceedings
Recommendation: The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F237 — Teamwork
Recommendation: There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance staff, and catering staff also needs to be recognised and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
10 — Establish partner Trust buddying arrangement
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff development and sharing approaches to problems. This arrangement is promoted …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
RHI-37 — Reduce Organisational Silos
Recommendation: In keeping with the spirit of the Ministerial Pledge of Office, the Northern Ireland political parties, supported by the Northern Ireland Civil Service, should together agree a set of actions to reduce organisational silos arising between the government Departments and …
Gov response: [Note: The NI Executive responded to recommendations 5-7, 25, 37, 39-43 together as a group under the 'Ministers and Special Advisers' theme.] NI Executive Response (October 2021): These recommendations can be accepted in full, with …
Accepted
No update 2+ yrs
R19 — ICN instructions recorded
Recommendation: Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Gov response: Section 4.2 of the Scottish Government's response details the professional standards for record-keeping for nurses and doctors. The revised NMC code requires nurses and midwives to complete all records at the time or as soon …
Accepted
LAMI-6 — Establish a Committee for Children and Families to coordinate inter-agency services
Recommendation: Each local authority with social services responsibilities must establish a Committee of Members for Children and Families with lay members drawn from the management committees of each of the key services. This Committee must ensure the services to children and …
Unknown
PFD Reports (145) — showing 100 most recent
Liam Sutton
Concerns: Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed critical care.
Pending
Andrew Hughes
Concerns: The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.
Response: Greater Manchester Integrated Care clarified that mental health services provide a crisis response, not an emergency response, which is the responsibility of 999 services. They acknowledge an ongoing risk regarding …
Response: The Deputy Mayor clarifies that their role is one of scrutiny and oversight for RCRP implementation, not operational accountability for GMP or partner agencies. They suggest future Regulation 28 notices …
Responded
Mark Vidler
Concerns: Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.
Response: Kent and Medway NHS Mental Health Trust has delivered refresher training focusing on patient-centred care and introduced regular service user/carer feedback. They are revising their Rapid Response Standard Operating Procedure …
Responded
Ricky Monahan
Concerns: An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines for fire escape protections in such settings.
Response: NHS England states that appropriate national guidance regarding patient safety and risk assessment in mental health settings already exists, implying the issue was with local implementation of environmental risk assessments …
Response: The Environmental Risk Assessment has been updated to include the fire escape, and the Trust has installed new metal fence panels and an eight-foot-high gate on the ground floor and …
Response: The CQC outlines its existing regulatory duties under Regulation 12 regarding safe care and treatment, and explains its inspection processes, but states the issue of national guidelines for fire escape …
Responded
Michael Moore
Concerns: Persistent NHS capacity constraints are causing significant and increasing delays in cancer referrals, diagnosis, and treatment, risking patient outcomes.
Responded
Doreen Swann
Concerns: Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.
Responded
Edward Cassin
Concerns: There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering patient care.
Responded
Malcolm Morris
Concerns: Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.
Responded
Abdulrahman Alajmi
Concerns: UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe transfer and treatment.
Overdue
Oladeji Omishore
Concerns: Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental health state during interaction.
Overdue
Tammy Milward
Concerns: Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.
Responded
William Hare
Concerns: Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.
Responded
Antony Williamson
Concerns: 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.
Responded
Anne Leake
Concerns: 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.
Responded
Jean Mullen
Concerns: Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear evidence of deteriorating capacity.
Responded
Bryan and Mary Andrews
Concerns: 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.
Responded
Kevin Woods
Concerns: 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.
Responded
Dennis Harry
Concerns: Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.
Responded
Susan Dear
Concerns: Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in patient discharge from hospitals.
Responded
Omar Ahmed
Concerns: Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health deterioration and inadequate living conditions.
Responded
Pauline Spedding
Concerns: Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks in care continuity and increased risk, highlighting systemic hospital capacity issues.
Responded
Megan Davison
Concerns: A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and DKA, alongside an inability to share patient records with private providers, impedes comprehensive care.
Responded
Judith Obholzer
Concerns: Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis team referrals, and delayed treatment plans for patients.
Responded
Richard Hardman
Concerns: The absence of a clear mechanism for a single lead practitioner to coordinate and integrate care across various medical disciplines and hospital sites in complex cases poses a risk.
Overdue
Patricia Eyken
Concerns: Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving treatment.
Responded
Robert Prowse
Concerns: Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and exacerbating emergency department overcrowding.
Responded
Sarah Sutherland
Concerns: A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate with NHS mental health services.
Overdue
Tobias Mannering-Jones
Concerns: Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency coordination.
Responded
Jacob Billington
Concerns: Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
Responded
Dorota Kuklinska
Concerns: Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, as clinicians were unaware of existing protocols.
Responded
Iona Buckingham
Concerns: The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.
Responded
Karena Wicking
Concerns: The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing anticoagulant prophylaxis for patients with reduced mobility.
Responded
Tom Sweeting
Concerns: Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
Responded
Barbara Woodman
Concerns: Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.
Responded
Charlene Roberts
Concerns: Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.
Responded
Michael Daft
Concerns: There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.
Responded
Sarah Read
Concerns: There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is unavailable when needed.
Responded
Lauren Bridges
Concerns: Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant communication failures.
Responded
Oleg Khala
Concerns: A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.
Responded
Jean Frickel
Concerns: Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, and local authorities continues to risk future deaths.
Overdue
Nigel Harper
Concerns: A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an intended urgent mental health assessment. This misunderstanding of urgent referral protocols poses a risk of future deaths.
Responded
Jessica Hodgkinson
Concerns: Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.
Overdue
Samuel Morgan
Concerns: A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.
Responded
Thomas Huntley
Concerns: Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.
Responded
Jordan Clare
Concerns: There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care frameworks, leading to fragmented support and increased risk during crises.
Responded
Nicola Norman
Concerns: The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.
Overdue
Molly-Ann Sergeant
Concerns: Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, poor council response to referrals, and a lack of understanding of Mental Health Act rights.
Responded
Eric Huber
Concerns: Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and multi-disciplinary discussions, compromised his care.
Overdue
Matthew Dale
Concerns: Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and actual care, hindering proper support for his complex needs.
Overdue
Derek Larkin
Concerns: Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.
Responded
Derek Shaw
Concerns: 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.
Responded
David Morganti, Winnie Barnes, Robert Conybeare and Anthony Reedman
Concerns: 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.
Responded
Lynn Moss
Concerns: The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high demand on EDs, fueled by broader health and social care failures.
Overdue
Glendys Roberts
Concerns: Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, vascular emergency pathways, and an ambulance handover plan has been unacceptably slow.
Responded
Charles Rothwell
Concerns: Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.
Overdue
Violet Howard
Concerns: There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.
Responded
Daniel Clements
Concerns: A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them being passed between agencies without effective crisis intervention or multidisciplinary planning.
Responded
Sarah Clarke
Concerns: 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.
Responded
Samuel Alban-Stanley
Concerns: Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.
Responded
Marvin Rue
Concerns: Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.
Overdue
Matthew McManus
Concerns: An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.
Responded
John Skinner
Concerns: A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Overdue
Michelle Jennings
Concerns: Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during prosecutions, with no clear mechanism for sharing lessons.
Overdue
Joy Burgess
Concerns: Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Responded
Mark Jones
Concerns: Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.
Responded
Oskar Nash
Concerns: Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.
Responded
Eirlys Roberts
Concerns: A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to their well-being.
Responded
Brian Wareham
Concerns: A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.
Responded
Hadley Savory
Concerns: There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.
Overdue
Martin Gibbons
Concerns: A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health bed waits were also exacerbated by fragmented commissioning.
Responded
Susan Adams
Concerns: Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.
Responded
Bathsheba Shepherd
Concerns: Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to a lack of documentation pose ongoing risks.
Overdue
Rory Attwood
Concerns: The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Responded
David Ball
Concerns: Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.
Responded
Elena Wells
Concerns: Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.
Responded
Reginald Collins
Concerns: An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable EMI placements. This delayed discharge and inappropriately occupied an acute hospital bed.
Overdue
Prince Fosu
Concerns: Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and risking critical issues being missed.
Responded
Gordon Fenton
Concerns: There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, hindering optimal integrated care.
Responded
Jake Perry
Concerns: Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require a named local consultant and consultation with the overseeing hospital's specialist department upon admission.
Responded
John Gregory
Concerns: Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating condition, including inaccurate record-keeping, contributed to significant neglect.
Overdue
Lewys Crawford
Concerns: A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.
Overdue
Julie Taylor
Concerns: The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor inter-agency communication and a severe lack of specialist acute learning disability beds.
Responded
Suzanne Roberts
Concerns: The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.
Overdue
Safoora Alam
Concerns: Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.
Responded
Charles Williamson
Concerns: A shortage of appropriate neuro-rehabilitation beds in Greater Manchester is preventing early effective rehabilitation, increasing the risk of complications and death.
Responded
Carol Jennings
Concerns: Inadequate and unchased referrals to the Tissue Viability Nurse, combined with systemic failures in detailed wound record-keeping, led to delayed and insufficient care for severe leg ulcers.
Responded
Daniel Shorrocks
Concerns: Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded by poor integration between care, mental health, and educational support services.
Responded
Richard Carlon
Concerns: The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health services missing opportunities to re-engage with a patient.
Responded
David Jukes
Concerns: Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the patient, despite being notified, creating significant risk.
Responded
Anthony Walker
Concerns: Specific concerns were unavailable as the text referenced an attached sheet.
Overdue
Georgia Nelson
Concerns: Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, contributed to a patient's death by suicide following a mental health relapse.
Responded
Nathan Cooke
Concerns: There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Overdue
Megan Jones
Concerns: A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.
Overdue
Yong Hong
Overdue
Peter Garvin
Concerns: Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively impacted patient care. A carer's assessment was also not offered.
Overdue
Janice Keelan
Concerns: No specific concerns were detailed in the provided text.
Responded
John Mellor
Concerns: There was a systemic failure to conduct required blood tests for renal failure patients due to unclear responsibilities, missing shared care arrangements, and reliance on patients to relay vital information to primary care.
Overdue
Paul Gillam
Concerns: Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between Addaction and the Community Mental Health Team.
Overdue
Robin McEwan
Concerns: Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Responded
Brian Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Overdue