Shropshire, Telford and Wrekin

Concerns summary The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it is standard practice.

Concerns summary A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.

Concerns summary A hospital discharged a patient without ensuring care arrangements were in place or that he could raise an alarm, leading to a critical delay in emergency assistance.

Concerns summary The hospital lacks a system to provide written information or counselling to patients, or their families, about new drug side-effects, potential complications, or actions to take, including for those without capacity.

Concerns summary The HGV licence medical process allows drivers to use independent GPs without access to full medical history, enabling them to hide disqualifying conditions and pose a road risk.

Concerns summary The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.

Concerns summary Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.

Concerns summary An untrained call handler failed to properly escalate a critical call, leading to inadequate action despite receiving important information. There was a systemic failure to appropriately handle and discuss the case.

Concerns summary The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall risks and unclear roles regarding patient assistance.

Concerns summary Road safety concerns at a blind bend include poor visibility for right turns from a driveway, inappropriate speed limits, and the absence of warning signs.

Concerns summary The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.

Concerns summary Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery impossible and contributed to the patient's death.

Concerns summary There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a Tissue Viability Nurse. This was compounded by a lack of clear guidelines for TVN referrals and involvement in prevention plans.

Concerns summary Systemic failures in child safeguarding include unclear referral pathways, delayed responses to urgent concerns, insufficient multi-agency understanding of complex family dynamics, and inadequate information sharing regarding children's welfare in private law proceedings.

Concerns summary Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not seen by the discharging doctor due to systemic record-keeping failures and inadequate alert systems.

Concerns summary Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols raised concerns for patient safety.

Concerns summary Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.

Concerns summary Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to inadequate examination and protocol adherence.

Concerns summary A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and conducted subjective risk assessments, further compounded by transitioning services and possible masking of symptoms.

Concerns summary Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent experience for an essential procedure.

Concerns summary Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a missed opportunity for a crucial helicopter deployment, potentially preventing death.

Concerns summary A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about the deceased's mental health and self-harm history were not escalated to a MASH meeting.

Concerns summary Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.

Concerns summary There was a critical lack of awareness and specific risk assessment for rip currents, inadequate warnings for those entering the water, and no clear guidance on how to escape them.

Concerns summary A crucial towpath gate, intended to be locked during high river levels, was open due to the absence of an effective notification system between agencies, posing ongoing flood safety risks.