Blackpool and Fylde

Concerns summary There were critical shortcomings in disseminating and understanding policy changes, specifically for Covid contact testing, leading to clinician confusion and policies not being consistently applied.

Concerns summary Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.

Concerns summary Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.

Concerns summary There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.

Concerns summary A critical lack of awareness among general paediatricians regarding rhabdomyolysis, a rare but serious condition in young children, risks missed diagnoses and fatal outcomes.

Concerns summary Despite prior concerns and reported improvements, there remains a persistent risk of sepsis going unrecognised and treatment being delayed at Blackpool Victoria Hospital.

Concerns summary The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information being disseminated to GPs.

Concerns summary 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.

Concerns summary Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.

Concerns summary A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.

Concerns summary Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis and treatment.

Concerns summary GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.

Concerns summary A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.

Concerns summary 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.

Concerns summary Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient safety.

Concerns summary Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.

Concerns summary Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised accurate care narrative and incident review.

Concerns summary A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.

Concerns summary Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised patient care.

Concerns summary Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.

Concerns summary Emergency Department staff were overwhelmed by excessive patient numbers, leading to delays in doctor assessment and undetected patient deterioration, creating a risk of future deaths.

Concerns summary Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

Concerns summary Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.

Concerns summary Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and inadequate consideration of previous medical records before discharge.

Concerns summary Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.