Shropshire, Telford and Wrekin

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 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 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 Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. Additionally, prescribed discharge medication was not provided.

Concerns summary Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.

Concerns summary Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a significant, unlit obstruction hazard to other road users.