Staffordshire and Stoke on Trent

Concerns summary A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical lack of protocol for radiology report delivery.

Concerns summary Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.

Concerns summary The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.

Concerns summary Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.

Concerns summary The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.

Concerns summary Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.

Concerns summary The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures for high-risk elderly patients.

Concerns summary A single-crewed bin lorry operated in hazardous conditions, and safety guidance for waste collection did not adequately address checking bins for persons, creating a risk for vulnerable individuals.

Concerns summary The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.

Concerns summary Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.

Concerns summary Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate advice and highlighting a lack of clear standards for inter-hospital information exchange.

Concerns summary Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. Hospital evaluation was insufficient, and staff lacked training on product changes and alternative actions.

Concerns summary An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its reduced bore size. This caused inadequate drainage, and the product is still misleadingly promoted.

Concerns summary It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.

Concerns summary The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.

Concerns summary There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.

Concerns summary A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.

Concerns summary Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack of escalation or specialist involvement.

Concerns summary A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.

Concerns summary Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical attention for post-discharge vomiting.

Concerns summary A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.

Concerns summary Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.

Concerns summary Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.

Concerns summary Prolonged social isolation for a patient with C. difficile negatively impacted her well-being, compounded by inadequate nutritional information recording and assessment.

Concerns summary A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.