2014

Concerns summary There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.

Concerns summary An excessive paracetamol dose was prescribed and dispensed due to inadequate staff training and procedures, compounded by a failure to review the dose or conduct necessary blood tests.

Concerns summary Concerns relate to inadequate dog management practices in a confined living space and fragmented, ineffective legislation on dog control that focuses on breed over behavior rather than public safety.

Concerns summary An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.

Concerns summary Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and how to commence CPR.

Concerns summary Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by community mental health workers.

Concerns summary There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on unqualified staff for medication initiation.

Concerns summary An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue oxygen delivery.

Concerns summary Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care plans.

Concerns summary The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.

Concerns summary There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.

Concerns summary Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and response.

Concerns summary Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, hindering proper risk assessment.

Concerns summary Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.

Concerns summary Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.

Concerns summary The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.

Concerns summary Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.

Concerns summary Employees developed complacency regarding health and safety due to routine work, exacerbated by a lack of standard procedures to remind them of lifting plans, risks, and infrequent safety briefings.

Concerns summary Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.

Concerns summary The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.

Concerns summary Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.

Concerns summary The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.

Concerns summary The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.

Concerns summary The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which risks lives.