2014

Concerns summary Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new standards.

Concerns summary Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.

Concerns summary Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or lack capacity.

Concerns summary Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.

Concerns summary Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.

Concerns summary NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.

Concerns summary Crucial literature on the dangers of co-sleeping is only available in English, preventing non-English speaking mothers from accessing vital safety information.

Concerns summary The inquest identified unresolved professional disagreements regarding the proper steps needed to prevent similar occurrences, which could not be adjudicated.

Concerns summary Inadequate inter-agency communication and a lack of shared knowledge, exacerbated by confidential Individual Management Reviews, prevented a comprehensive understanding of mutual concerns.

Concerns summary Poor communication led to a missed patient appointment. A health trust also failed to engage with the fire service, preventing vulnerable individuals from receiving crucial home safety checks due to a lack of information sharing.

Concerns summary Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.

Concerns summary The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.

Concerns summary Inadequate clinician response to failed home visits included lack of client contact and failure to escalate issues. Policies for escalation, welfare checks, and auditing failed visits require urgent review.

Concerns summary Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of similar road deaths.

Concerns summary All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.

Concerns summary An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.

Concerns summary A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.

Concerns summary The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.

Concerns summary Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.

Concerns summary Missed opportunities to refer to critical care, compounded by a lack of recorded observations over 27 hours, suggest systemic failures in patient monitoring and escalation of care.

Concerns summary Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP was unaware of crucial hospital admissions and mental health involvement.

Concerns summary The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.

Concerns summary The wide access way to a car park, shared by pedestrians and vehicles, has a potentially unsafe layout that could be improved with better markings or physical dividers.

Concerns summary Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.