2014

Concerns summary The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph speed limit, creating a high risk of collisions.

Concerns summary Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, with conflicting information between the written discharge and verbal understanding.

Concerns summary There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.

Concerns summary The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.

Concerns summary CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.

Concerns summary A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.

Concerns summary The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.

Concerns summary A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review to prevent future collisions.

Concerns summary A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and the crossing moved further into Westhead Avenue to improve safety.

Concerns summary Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.

Concerns summary An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.

Concerns summary The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly as the limit increases on approach, contributing to repeated incidents.

Concerns summary There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.

Concerns summary Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.

Concerns summary A critical failure occurred in communicating recent haemoglobin test results to the surgical team. This information was vital for assessing surgical fitness and could have altered treatment or delayed surgery.

Concerns summary Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.

Concerns summary A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.

Concerns summary Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.

Concerns summary Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the curb can deflect speeding vehicles onto the pavement. Physical speed reduction measures are needed.

Concerns summary Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.

Concerns summary Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.

Concerns summary Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for mental health assessments, hindering timely risk identification and management for vulnerable patients.

Concerns summary Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.

Concerns summary This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not been implemented, posing ongoing safety risks.

Concerns summary The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.