Black Country

Concerns summary A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central road markings, leading to multiple incidents.

Concerns summary There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.

Concerns summary The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services raising concerns.

Concerns summary Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk assessments for Speech and Language Therapy referrals for dysphagia.

Concerns summary Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed in subsequent actions.

Concerns summary The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are insufficient to embed these critical safety practices.

Concerns summary Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed suicide/self-harm concerns before release.

Concerns summary A shared service road dangerously lacks designated pedestrian pathways, clear markings, or warning signs. Obstructions like bins and parked vehicles further reduce visibility and hinder emergency vehicle access.

Concerns summary Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.

Concerns summary The confusing design of a road junction, featuring conflicting traffic lights and inadequate pedestrian signals, creates a significant and unclear crossing risk for pedestrians.

Concerns summary Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.

Concerns summary Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. Inadequate qualitative training assessment and lack of post-incident training pose a significant patient safety risk.

Concerns summary A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.

Concerns summary Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for future lockdown scenarios.

Concerns summary Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.

Concerns summary An unqualified and inexperienced employee worked on a roof without proper training, a CSCS card, or designated supervision, indicating a lack of structured training programs and adequate supervisory arrangements.

Concerns summary An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail assessment, highlighting a lack of national guidelines for falls prevention in emergency departments.

Concerns summary A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.

Concerns summary The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, and not updating care plans or identifying patterns in the deceased's repeated falls.

Concerns summary Oxygen cylinder regulators present an ignition risk, possibly due to incorrect valve operation by paramedics lacking knowledge of safety protocols, with multiple reported incidents despite no identified device defects.

Concerns summary Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to her family or GP, leaving a vulnerable patient unmonitored.

Concerns summary An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction entries in medical records.

Concerns summary An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in community patients posed significant risks.

Concerns summary A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for their cultural diet and eating practices.

Concerns summary 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.