South Yorkshire East

Concerns summary The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.

Concerns summary Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, risking patient harm.

Concerns summary There is insufficient awareness and communication regarding the fire risks of emollient creams near heat, particularly for vulnerable individuals. Current reporting systems for related deaths also show significant discrepancies.

Concerns summary Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation or learning review occurred for eight months.

Concerns summary There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.

Concerns summary A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control and risking catastrophic accidents for road users.

Concerns summary The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and treating a patient's fractures.

Concerns summary Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear evidence of deteriorating capacity.

Concerns summary There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral information.

Concerns summary A critical failure exists in care home fire safety, as staff lack formal systems and training for checking residents after fire alarm activations, despite management claims of improvements.

Concerns summary A lack of automatic cardiology referral procedures led to sub-optimal cardiac failure management, and poor inter-departmental communication caused delayed and uncoordinated wound care.

Concerns summary Poor and inconsistent record keeping on a frailty unit, including lack of documentation for patient behaviour and professional assessments, prevented effective management and communication. There was also no system for agency staff to access policies.

Concerns summary Custody sergeants lacked understanding of Liaison and Diversion team processes, available information, and how to complete pre-release risk assessments. This indicates a training need for recognizing vulnerability at discharge.

Concerns summary Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual daily contact.

Concerns summary The public lacks crucial understanding and awareness regarding their responsibility to report motorway incidents, despite existing SMART motorway campaigns, leaving stationary vehicles a significant hazard.

Concerns summary A "blind spot" in door alarm systems for vulnerable people creates a potential danger, and other users may be unaware of this significant safety flaw.

Concerns summary A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.

Concerns summary Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.

Concerns summary Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients at risk of falls.

Concerns summary Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.

Concerns summary Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay in providing thromboprophylaxis.

Concerns summary Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred due to staff channelling medical issues through managers, who then underestimated the situation's seriousness.

Concerns summary Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.

Concerns summary The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing risk to drivers.

Concerns summary A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.