2014

Concerns summary A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.

Concerns summary The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.

Concerns summary The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.

Concerns summary There was no clear protocol for signposting individuals struggling to accept decisions or outcomes, and little consideration was given to re-signposting to other support agencies.

Concerns summary Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, hindering timely intervention and oversight.

Concerns summary Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.

Concerns summary Unilluminated and obscured street lamps caused dangerously poor road illumination, likely impairing the driver's ability to see the deceased on the carriageway.

Concerns summary Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest systemic failures in patient monitoring and escalation of care.

Concerns summary Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP was unaware of crucial hospital admissions and mental health involvement.

Concerns summary A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication prescriptions.

Concerns summary A disengaged seatbelt left a passenger unrestrained, leading to fatal injury; a seat belt alarm would have alerted carers to this safety risk.

Concerns summary The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.

Concerns summary The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only on sight and hearing tests, despite potential cognitive impairment like dementia.

Concerns summary The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings or physical dividers.

Concerns summary Lack of basic first aid training among train and station staff prevented the recognition and proper management of a critical medical emergency, specifically airway occlusion.

Concerns summary Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.

Concerns summary Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.

Concerns summary The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.

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 Critical test results were not communicated effectively between departments, to the patient, or to the GP, resulting in a missed diagnosis and suboptimal care, which was inadequately reviewed by a serious incident investigation.

Concerns summary The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.

Concerns summary Inadequate procedures for wheelchair checks resulted in faulty equipment, while communication breakdowns led to doctors being misinformed about a patient's injury despite staff and family concerns.

Concerns summary A patient with a head injury was inappropriately streamed to a GP clinic instead of the Emergency Department, indicating a critical failure in triage protocols, which was impeded by the CCG.

Concerns summary Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.

Concerns summary There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell disease, particularly concerning routine GI protection.