Staffordshire and Stoke on Trent

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 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 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 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 A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying a pneumonia diagnosis.

Concerns summary Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent serious fall.

Concerns summary A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising concerns about monitoring during transit.

Concerns summary Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.

Concerns summary A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting in a fatal collision and highlighting pedestrian visibility issues for large vehicles.

Concerns summary Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication between organisers and the Army contributed to the death.

Concerns summary Nursing staff consistently failed to adhere to critical dietary and drink restrictions for a patient with Down's Syndrome, despite explicit instructions, raising significant risks of aspiration.

Concerns summary A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.

Concerns summary Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally instructed or acted upon by clinical staff.