2014

Concerns summary The ward suffered from a lack of clear leadership, insufficient staffing, and uncoordinated patient care. Critical failures included a missing notes protocol, and no clear procedure for managing refusal of vital checks or escalating severe hyperglycaemia.

Concerns summary Prior to review, concerns existed regarding triage being performed by non-senior nurses without adequate training, and departmental policy failing to consistently consider the effects of warfarin on patients.

Concerns summary Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.

Concerns summary Road safety was compromised by a failure to treat the surface according to adverse weather plans and by the Route Steward not reporting hazardous running water across the carriageway.

Concerns summary Multiple clinical management failures included inappropriate prescribing, delayed chest drain insertion, and poor communication of consultant findings. The Medical Registrar failed to conduct crucial pre-procedure checks, compounded by confusing medical records and absent consultant respiratory cover.

Concerns summary National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.

Concerns summary A critical brain scan was misinterpreted by a general radiologist instead of a neuro-radiologist, highlighting a failure to follow existing guidelines for specialist interpretation and requiring a review of current protocols.

Concerns summary Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.

Concerns summary Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, compounded by a lack of clear police protocol for reporting such hazards.

Concerns summary Critical abdominal X-ray findings indicating small bowel obstruction were overlooked, leading to an inappropriate discharge and delayed re-admission. Additionally, prescribed discharge medication was not provided.

Concerns summary The GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing critical delays in treatment.

Concerns summary Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.

Concerns summary Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency were compounded by significant delays in reporting serious incidents under RIDDOR.

Concerns summary The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.

Concerns summary The dispatch system inadequately captured methadone overdoses and patient solitude. Welfare checks were not actioned, resulting in a three-hour delay in paramedic response to an overdose.

Concerns summary Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent treatment.

Concerns summary A gastric bypass procedure inadvertently led to hernia strangulation and death in a bariatric patient. The surgeon's revised practice of using sleeve gastrectomy for patients with hernias should be nationally disseminated.

Concerns summary Critical delays occurred in locating a patient due to ambulance service staff lacking training on finding callers with incomplete address information and inadequate communication protocols with BT. Subsequent investigations and revised protocols were also insufficient and poorly implemented.

Concerns summary Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of Abortion Act amendments. Foeticide should be considered before induction at this stage.

Concerns summary Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate treatment and a lack of necessary barrier nursing, highlighting failures in inter-hospital documentation.

Concerns summary The care home had inconsistent fall risk assessments for Mrs. Bulmer, failed to promptly implement identified risk-minimising measures, and did not review the assessment after multiple falls, indicating systemic failures in falls prevention.

Concerns summary A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.

Concerns summary Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.

Concerns summary The delivery vehicle involved in the collision lacked an automatic audible reverse warning device. There is no legislative requirement for such safety features on light commercial vehicles, creating an unnecessary risk.

Concerns summary The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.