Lancashire and Blackburn with Darwen

Concerns summary There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.

Concerns summary Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.

Concerns summary Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.

Concerns summary The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine courier services appears unclear, potentially leading to unsafe practices or misapplication of regulations.

Concerns summary The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.

Concerns summary Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.

Concerns summary Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic abuse histories persist, despite known risks and previous reviews.

Concerns summary The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety issues.

Concerns summary A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still be in use in other hospitals despite safer alternatives existing.

Concerns summary A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.

Concerns summary Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to the patient's death.

Concerns summary An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.

Concerns summary Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.

Concerns summary Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.

Concerns summary Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.

Concerns summary Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.

Concerns summary Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. Staff also lacked adequate training.

Concerns summary A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.

Concerns summary The provided text is incomplete and does not detail specific concerns.

Concerns summary The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.

Concerns summary Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up on referrals. Additionally, no internal investigation was conducted into the death.

Concerns summary No specific concerns are provided in the truncated text.

Concerns summary The concerns text for this report is incomplete, so specific issues cannot be identified.

Concerns summary The concerns text for this report is incomplete, so specific issues cannot be identified.

Concerns summary There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.