James Francis

1. 1. inadequate shift handover communication

   “In my opinion there ts a risk that future deaths will occur unless action is taken”

2. 2. delayed medical response

   “Delay in calling a GP or making a 111 call for advice & information given to GP when”

3. 3. inadequate clinical handover to emergency services

   “the Ambulance crew received the call to attend Deerswood at 15 22 and arrived at 15 25 They reported that they found Mr [name redacted] on the floor leaning up against the dining room chair and over to his right side They accepted that they were assertive but felt this was born from a frustration to find a time critical patient in such a position and staff were unable to answer basic questions about past medical history, allergies, mobility, communications for current medication It”

4. 4. insufficient staff training

   “staff members that they had received no training at all or it was some time (up to 3 years) since they had had any basic first aid training”

5. 5. lack of standardized clinical handover documentation

   “In addition, the paramedic suggested that other care homes have a key document that can be instantly handed over to them to speed up the handover procedure and ensure that clinical staff have a full history key information This Is often called a Hospital Passport and uses simple traffic light alerts to highlight key information”

6. 6. underestimation of minor trauma risks

   “heard expert evidence from Prof [name redacted], consultant neurosurgeon and prehospital care specialist at Imperial College”

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