2013

Concerns summary Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.

Concerns summary Patients admitted via their GP experienced significant delays in medical review compared to those from the Emergency Department, with one patient waiting six hours.

Concerns summary Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.

Concerns summary Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, compromising resident safety.

Concerns summary The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.

Concerns summary Npower failed to recognise a clearly vulnerable person, disconnecting their power despite staff concerns. Systemic failures in consumer protection and inadequate industry-wide changes risk future deaths.

Concerns summary Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.

Concerns summary Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.

Concerns summary The provided text is truncated and does not clearly state the specific concerns identified by the coroner.

Concerns summary Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority staff on home fire safety checks increase fire risks for the elderly.

Concerns summary An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.

Concerns summary Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.

Concerns summary Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.

Concerns summary Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.

Concerns summary A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs in the intermediate care unit lacked access to electronic hospital notes, impeding effective treatment.

Concerns summary The provided concerns text is too truncated to identify specific safety issues.

Concerns summary Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.

Concerns summary Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.

Concerns summary Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.

Concerns summary Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units to minimise this risk.

Concerns summary A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.

Concerns summary Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed to patient harm. Procedural errors, such as issuing an outpatient appointment to an inpatient, were also noted.

Concerns summary A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, contributing to pneumonia, and a 'nil by mouth' decision was made with insufficient evidence.