2014

Concerns summary Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.

Concerns summary The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.

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 The nursing home had an unreliable patient observation system, expired First Aid certifications, staff incompetence in CPR, and concerns regarding care quality due to excessively long shifts.

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 The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design improvements like higher barriers, as seen in modern car parks, are needed to deter jumps.

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 high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.

Concerns summary Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are needed to secure prescription medication from family members with a history of overdoses.

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 Patients had unlimited and unsupervised access to alcohol-based hand sanitising gels, enabling decanting and storage in rooms. Staff lacked awareness of the gels' alcohol content and potential for ingestion, posing a significant safety risk.

Concerns summary The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.

Concerns summary A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is a delay in finalising and implementing updated national guidance for neonatal hypoglycaemia management.

Concerns summary Concerns relate to the adequacy of support for sole carers, comprehensive mental health risk assessment, and the balance between patient wishes and the broader family's well-being, particularly for those under significant stress.

Concerns summary Poor GP documentation, lack of routine monitoring, and a presumption of psychological problems without excluding organic causes led to delayed diagnosis of an underlying physical condition. Systemic failures in electrolyte management and inter-service communication were also identified.

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.

Concerns summary Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.