Derby and Derbyshire

Concerns summary The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded by false reassurance from NEWS scores, led to missed opportunities for earlier treatment.

Concerns summary Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.

Concerns summary GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an adequate mental health risk assessment; internal reviews also failed to identify these critical errors.

Concerns summary New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.

Concerns summary The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.

Concerns summary The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.

Concerns summary Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses an ongoing risk, despite awareness of the need for improvements.

Concerns summary Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.

Concerns summary Systemic barriers prevented social workers from sharing crucial falls history with multi-agencies, and investigations failed to adequately review past falls risk assessments, risking future deaths.

Concerns summary The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.

Concerns summary The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.

Concerns summary There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.

Concerns summary Light goods vehicles with significant rear blind spots are widely used without mandatory reversing aids like cameras or audible warnings, increasing the risk of fatal collisions with pedestrians.

Concerns summary Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.