2014

Concerns summary There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.

Concerns summary Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a systemic failure risking patient safety and future deaths.

Concerns summary Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.

Concerns summary There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.

Concerns summary Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.

Concerns summary An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.

Concerns summary There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.

Concerns summary A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures are needed.

Concerns summary The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.

Concerns summary The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.

Concerns summary Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.

Concerns summary Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety hazard.

Concerns summary Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.

Concerns summary Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage sick children effectively.

Concerns summary The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of future deaths and needs policy review.

Concerns summary Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a significant, unlit obstruction hazard to other road users.

Concerns summary Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, document checks, or access medical history, and BUPA's investigation was insufficient.

Concerns summary Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.

Concerns summary Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect warnings.

Concerns summary The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and posing risks to pedestrians and vehicles.

Concerns summary The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.

Concerns summary North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.

Concerns summary Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.

Concerns summary A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.

Concerns summary Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.