Poor prevention and early intervention
92 items
2 sources
Over-reliance on hospital discharge solutions rather than prioritising prevention and early intervention strategies in health and social care.
Cross-Source Insight
Poor prevention and early intervention has been flagged across 2 independent accountability sources:
2 inquiry recs
90 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (2)
1 — Monitor Brook House contract performance robustly
Recommendation: The Home Office must actively and robustly monitor the performance of the Brook House contract, including satisfying itself that any self-reported information is accurate. This may include engagement with monitoring bodies and appropriate stakeholders. Penalties must be attached to inadequate …
Gov response: The Home Office has introduced new contracts requiring internal audit programmes and self-reporting by service providers. Two Home Office teams operate in each IRC: detention services compliance teams for on-site contract monitoring, and Detention Engagement …
Accepted in Part
Delivered
6 — Review and reduce cell lock-in periods
Recommendation: The Home Office, in consultation with the contractor responsible for operating each immigration removal centre, must review the current lock-in regime and determine whether the period of time during which detained people are locked in their cells could be reduced. …
Gov response: A maximum 9-hour overnight lock-in period has been implemented. The government has also noted a drive to improve the range of activities available to detainees.
Accepted in Part
Delivered
PFD Reports (90)
Oliver Long
Concerns: The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health information regarding these risks.
Overdue
Milos Jankovic
Concerns: Inadequate follow-up for Barrett’s oesophagus in primary care, including a lack of routine recall and prompts for GPs to consider endoscopy, is leading to missed surveillance and preventable cancers.
Overdue
Noreen McGlynn
Concerns: There was a lack of capacity for community healthcare teams and GPs to offer home rehydration for a dehydrated patient, leading to unwanted hospital admission despite family preferences for home care.
Responded
Sarah Lewis
Concerns: Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Responded
Daniel Hatchett
Concerns: GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Responded
Jeanette Sidlow Beech
Concerns: Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely jeopardizing lives.
Responded
James Smith
Concerns: Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency care.
Responded
Christian Hobbs
Concerns: Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Responded
Andrew Waters
Concerns: Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.
Responded
Barry Myers
Concerns: Insufficient funding prevents the provision of urgent mechanical thrombectomy services between 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.
Responded
Diana Fairweather-Purkis
Concerns: Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
Responded
Aeran Taylor
Concerns: Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with substance abuse were identified.
Responded
Harry Southern
Concerns: Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential funding cuts.
Responded
Paul Taylor
Concerns: 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.
Responded
Oliver Barnett
Concerns: The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring parents to manage complex detoxification at home.
Responded
Erik Marshall
Concerns: A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.
Responded
Ronald Spencer
Concerns: Persistent and inadequately addressed national NHS staffing shortages, intensified by chronic "winter pressures," lead to significant treatment delays and avoidable deaths, exacerbated by a lack of cohesive, long-term planning.
Overdue
Andrew Ewin-Ripp
Concerns: Lengthy neurology waiting times, absence of mandatory annual GP epilepsy reviews, lack of clear national guidance for long-term monitoring, and poor communication of critical post-discharge information risk patient safety.
Responded
Isaac Onyeka
Concerns: Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for darker skin tones pose risks.
Responded
Alfie Nicholls
Concerns: Poor understanding and recognition of Avoidant Restrictive Food Intake Disorder (ARFID) among professionals, coupled with inadequate cross-sector strategies and non-holistic care planning, increased risks for vulnerable children.
Responded
Kirandip Bharaj
Concerns: Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of eating disorders, risking unaddressed, urgent medical needs for vulnerable service users.
Responded
Brenda Shields
Concerns: The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.
Responded
Odessa Carey
Concerns: Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating policy. Premature discharge from community treatment lacked engagement and proper care coordination.
Overdue
Louis Rogers
Concerns: Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, contributed to missed opportunities for timely intervention and specialist referral.
Overdue
Twm Bryn
Concerns: Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks proactive monitoring.
Responded
Daniel Tilley
Concerns: Insufficient funding and staffing within police Communication and Control Units, compounded by inadequate officer numbers, consistently prevent timely responses to incidents, a long-standing issue particularly acute during peak demand.
Responded
Graham Flindle
Concerns: 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.
Responded
Jade Hutchings
Concerns: Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable older adolescents, missing crucial support opportunities.
Responded
Charley Patterson
Concerns: A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged waiting times (up to 63 weeks) for treatment. Current services and resources are insufficient to meet this drastically increased demand.
Overdue
Robyn Skilton
Concerns: Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.
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
Spencer Barr
Concerns: 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.
Overdue
Susan Carling
Concerns: High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.
Overdue
REDACTED
Concerns: Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services in the North Warwickshire area.
Overdue
Jack Ritchie
Concerns: Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training for medical professionals contributed to a preventable death.
Overdue
Yousef Makki
Concerns: A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding of the inherent risks.
Responded
Maya Zab
Concerns: There's been an concerning increase in severe nutritional anaemia and related deaths in children, potentially due to reduced health consultations, limited social contact, and widening socio-economic inequalities exacerbated by the pandemic.
Responded
Steven Regoli
Concerns: Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.
Overdue
Nicholas Spooner
Concerns: There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are often denied adequate support.
Overdue
Anastasia Uglow
Concerns: There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.
Responded
Owen Hinds
Concerns: A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to fall between existing care criteria.
Responded
Averil Hart
Concerns: Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.
Responded
Cyril Cheetham
Concerns: The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.
Responded
Violet Jackman
Concerns: Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.
Responded
Michelle Turner
Concerns: Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and substance misuse, may be lost, jeopardizing vital services.
Responded
Carolyne Senior
Concerns: Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.
Responded
Reggie-Jay Payne
Concerns: Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not administered, potentially contributing to the baby's death.
Overdue
Rifky Grossberger
Concerns: Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed to the risk.
Responded
REDACTED
Concerns: There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.
Responded
Mohan Acharya
Concerns: Emergency department crowding is a significant risk factor associated with increased mortality among admitted patients, contributing to approximately 500 deaths annually.
Responded
Reece Lapina-Amarelle
Concerns: There's a systemic failure to provide integrated treatment for co-occurring serious mental illness and substance misuse, hampered by poor information sharing and an outdated Mental Health Act.
Responded
Noah Lomax
Concerns: The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.
Responded
Jack May
Concerns: Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."
Responded
Douglas Minns
Concerns: The withdrawal of a dedicated falls service, which previously assisted and assessed fallen individuals, is now dangerously delaying response times and putting vulnerable patients' lives at risk.
Responded
Neil Swaisland
Concerns: The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.
Responded
Edward Farmer
Concerns: A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals and the importance of timely medical intervention.
Responded
David Sargeant
Concerns: The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, and impracticalities of out-of-county referrals for ongoing care.
Responded
Enric Elliott
Concerns: Vulnerable young mothers who book late for maternity care are often excluded from the Family Nurse Partnership due to rigid gestation limits, despite late booking indicating increased risk.
Responded
Alfie Scambler-Holt
Concerns: The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.
Overdue
Karen Edgar
Concerns: Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.
Overdue
Bernard Gerrard
Concerns: Emergency ambulance services are experiencing unacceptable delays in vehicle response times, even for urgent calls, due to insufficient funding and overwhelming demand.
Overdue
William Abrahams
Concerns: The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.
Responded
Raymond Davidson
Concerns: Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.
Overdue
Charlie Craig
Concerns: British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.
Responded
Evelyn Fisher
Concerns: The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals with unrecognised cognitive impairment from driving.
Overdue
Tomas Kelly
Concerns: Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.
Responded
Jamie Pashley
Concerns: The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol liaison nurse post-discharge.
Overdue
John Haughey
Concerns: The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this hazard and the need for formal risk assessments across sectors.
Overdue
Isabel Gentry
Concerns: The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.
Overdue
Annabel Lewis
Concerns: Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.
Overdue
Vadims Aleksejevs
Concerns: There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable homeless individuals on campsites, and an unclear statutory duty to house them.
Responded
Thomas Green
Concerns: There was a critical failure to action a psychiatric referral during inpatient care and no follow-up for complex PTSD post-discharge. This highlighted a commissioning gap for suitable services for complex mental health conditions.
Overdue
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Responded
Christina O’Brien
Concerns: Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.
Overdue
Simon Klineberg
Concerns: Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk patients.
Overdue
William Higgleton
Concerns: A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, creating a risk of future deaths.
Overdue
Curt Falk
Concerns: A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.
Responded
Isabella Drew
Concerns: Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.
Responded
Emma Carpenter
Concerns: Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health and education systems.
Responded
Baby Olsberg
Concerns: Antenatal screening for Group B Streptococcus (GBS) and prophylactic intrapartum antibiotics for positive cases are not routinely offered by the NHS, potentially putting babies at risk.
Responded
Aleysha McLoughlin
Concerns: The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.
Responded
Sian Armstrong
Concerns: A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.
Overdue
Emmanuel Akinmuyiwa
Concerns: The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.
Overdue
Helena Farrell
Concerns: Critical failures included an inadequate CAMHS referral system with insufficient staffing and training, a failure to recognise escalating risks, and a school counsellor lacking verified qualifications and professional oversight.
Responded
Samarjit Singh
Concerns: The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Overdue
Oliver Hiscutt
Concerns: Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.
Overdue
Amanda Vickers
Concerns: A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.
Responded
Amna Umer Ahmed
Concerns: Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.
Response: The Royal College of General Practitioners supports joint working to raise awareness of Sudden Adult Cardiac Death syndrome among GPs and has consulted the British Heart Foundation on this. They …
Overdue
Ann Margaret Spearing
Concerns: Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not to have a treatable condition.
Response: Bristol CCG is re-procuring specialist mental health and learning disability services for more flexible, person-centred care. They have also implemented an enhanced advice and guidance scheme for GPs, including clinician …
Responded
Mena Terefi
Concerns: Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Overdue