2014

Concerns summary A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.

Concerns summary A critical failure in emergency triage assigned a low priority 'code green' to a call concerning the ingestion of multiple potentially fatal tablets.

Concerns summary A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.

Concerns summary No specific concerns were detailed in the provided text for summarization.

Concerns summary Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.

Concerns summary There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.

Concerns summary Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a systemic failure risking patient safety and future deaths.

Concerns summary An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.

Concerns summary There is limited public awareness and insufficient research regarding the risk of positional asphyxia associated with baby slings.

Concerns summary A duty manager's decision not to grit roads based on inaccurate weather assessment led to dangerous conditions; improved information sharing and review of council procedures are needed.

Concerns summary The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.

Concerns summary The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.

Concerns summary Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.

Concerns summary The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.

Concerns summary North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.

Concerns summary Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.

Concerns summary There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.

Concerns summary The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.

Concerns summary CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.

Concerns summary There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.

Concerns summary Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.

Concerns summary Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.

Concerns summary A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.

Concerns summary Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.