2015

Concerns summary A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.

Concerns summary Repeated family concerns about abdominal pain and rising infection markers were not documented, escalated to medical teams, or examined, leading to a significant delay in diagnosing a critical condition.

Concerns summary Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment of detained patients led to unsafe conditions.

Concerns summary The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.

Concerns summary Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, inadequate interpretation of radiology findings, and improper use of early warning scores for sepsis.

Concerns summary The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.

Concerns summary Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.

Concerns summary The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.

Concerns summary Critical communication failures between primary care and podiatry, coupled with a lack of ownership in referral processes and administrative errors, caused significant delays in secondary care access.

Concerns summary There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading to inadequately assessed individuals being permitted to drive.

Concerns summary The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.

Concerns summary There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for medical interventions was also absent.

Concerns summary Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.

Concerns summary Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.

Concerns summary The absence of clear protocols and an overemphasis on student autonomy led to delayed intervention and reluctance to force entry for a student in distress, risking future deaths.

Concerns summary Emergency response procedures were inefficient, with delays in contacting emergency services, inadequate first aid provision, and difficulties for paramedics locating the casualty on-site.

Concerns summary There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.

Concerns summary Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.

Concerns summary There was confusion and unreasonable delay in transferring an acute aortic dissection patient to a tertiary center, including a failure to escalate the transfer decision to a consultant.

Concerns summary The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of its procedures.

Concerns summary Staff lacked specific, prescribed training on how to properly conduct and record observations of residents.

Concerns summary There is no joint guidance for "Can't Intubate Can't Oxygenate" situations when both anaesthetists and ENT surgeons are present, leading to inconsistent clinical judgments and limited practitioner experience.

Concerns summary The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.

Concerns summary An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in patient assessment by qualified healthcare professionals.