Staffordshire and Stoke on Trent

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 Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.

Concerns summary The hospital failed to conduct a serious untoward incident review or root cause analysis, limiting critical examination of decisions. Additionally, a necessary consultant-led out-of-hours rota for post-surgery patients was not yet implemented.

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 A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are no warning signs for pedestrians or motorists regarding this dangerous crossing point.

Concerns summary A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major roundabout lacks a pedestrian crossing. Other local roads have adopted lower limits for safety.

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 pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. Referrals to specialists were also delayed.

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 Concerns were raised about a perceived lack of staff over a bank holiday leading to delayed interventions, alongside poor nutritional support, inadequate pain control, and poor communication from nursing staff.

Concerns summary Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.

Concerns summary Inadequate street lighting and crossing facilities on Church Street, especially near St Edwards Church, increased the risk to elderly pedestrians crossing the road.

Concerns summary A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns about potential dangers to users.

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.