Blackpool and Fylde

Concerns summary Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were often unaware of residents needing assistance, posing risks.

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 Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.

Concerns summary Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.

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 Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.

Concerns summary Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.

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 Care workers prematurely leaving visits based solely on task completion and apparent contentment risks overlooking potential welfare concerns due to insufficient interaction time with vulnerable service users.

Concerns summary Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, leading to fragmented and unreliable care.

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.

Concerns summary Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or engage. This systemic ambiguity puts vulnerable patients at risk due to inadequate monitoring.

Concerns summary Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.

Concerns summary A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.

Concerns summary An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of reduced Christmas staffing levels.

Concerns summary There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.