2014

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 There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.

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 Poorly designed bicycle lanes and confusing signage at a junction create significant dangers for cyclists due to tramlines, forcing unsafe crossing angles and conflicts with pedestrians.

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 Systemic failures included untimely police response, poor inter-agency communication, and inappropriate use of Mental Health Act powers due to resource limitations. Concerns also raised about non-medically qualified clinical decision-making and lack of GP communication.

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 Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.

Concerns summary Severe systemic failures included lack of out-of-hours cardiology consultant cover, critical drug shortages, and inadequate facilities for specialist procedures. Additionally, poor communication, failure to assess mental capacity, and obtain consent for treatment were identified.

Concerns summary Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for landlords to proactively check or replace it unless it breaks or during refurbishment.

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 absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.

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 A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.

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 A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.