2014

Concerns summary Inadequate pre-operative assessment and failure to secure an HDU bed for a high-risk patient were major concerns. Insufficient ITU bed capacity due to nursing shortages further compromises patient care.

Concerns summary The pendant alarm provider failed to adequately inform customers about additional safety features, specifically the option to link to fire alarms, creating an unaddressed fire risk for vulnerable users.

Concerns summary Hospital staff experienced critical failures in contacting the Haematology Department and receiving timely responses from haematologists, putting patient lives at risk due to lack of specialist advice.

Concerns summary Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.

Concerns summary The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.

Concerns summary The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.

Concerns summary Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.

Concerns summary The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.

Concerns summary E-cigarette batteries charged via universal micro USB ports are at risk of explosion if an incompatible charger supplies the wrong current.

Concerns summary The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing a high-risk patient's mobility.

Concerns summary Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.

Concerns summary Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.

Concerns summary The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.

Concerns summary Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action until a Coroner's report was issued, despite earlier recommendations.

Concerns summary The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a serious risk of injury or death from impact with the external door.

Concerns summary Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting continuity of care.

Concerns summary Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system enhancements.

Concerns summary New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.

Concerns summary There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.

Concerns summary Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.

Concerns summary The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.

Concerns summary Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in the area at significant risk.

Concerns summary Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.

Concerns summary Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.

Concerns summary Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking water users' safety.