South Yorkshire East

Concerns summary Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.

Concerns summary Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.

Concerns summary Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Concerns summary A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.

Concerns summary A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying crucial diagnosis and treatment.

Concerns summary Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.

Concerns summary The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.

Concerns summary Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.

Concerns summary The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, unnecessarily increasing the risk of collisions.

Concerns summary A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.

Concerns summary Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment plans.

Concerns summary There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed Amiodarone, particularly concerning liver, thyroid, and respiratory function during the initial treatment period.

Concerns summary Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.

Concerns summary Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.

Concerns summary There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.

Concerns summary Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.

Concerns summary There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.

Concerns summary Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.