2015

Concerns summary The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.

Concerns summary The Sheppey Road Bridge has a history of rear-end collisions due to its geometry affecting visibility and high speeds. Despite a safety review recommending a 50 mph limit, the speed limit remains 70 mph.

Concerns summary Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.

Concerns summary Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.

Concerns summary Concerns were raised about the lack of regulation and licensing for the sale of e-cigarette fluid.

Concerns summary Mrs Harris was discharged from the Minor Injuries Unit without a doctor's review, consideration of anticoagulant therapy, or assessment of potential immobility effects from her injury.

Concerns summary The RSSB Rule Book is flawed as it only permits stopping trains to prevent damage, not to protect individuals in danger from a train.

Concerns summary Inadequate signage and road layout on London Bridge encourage speeding, with insufficient prominent 20 mph speed limit signs and a lack of separate lanes for cyclists.

Concerns summary Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.

Concerns summary There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment during the hospital triage process.

Concerns summary There was a critical failure to provide out-of-hours access to flexible sigmoidoscope equipment, and no clear, accessible protocol for staff regarding such access even 18 months later.

Concerns summary The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.

Concerns summary Effective communication systems between families/carers and staff are not routinely followed or audited, and understanding of early discharge plans is inconsistent, hindering seamless patient transitions.

Concerns summary Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.

Concerns summary Driver inexperience and the commander's failure to wear a safety harness, due to permitted discretion and lax enforcement of standing orders, led to the fatal incident.

Concerns summary The ambulance service's call-handler script for 'breathing difficulties' critically omits questions about chest pain, potentially delaying appropriate emergency response for cardiac-related issues.

Concerns summary A policy gap exists for managing patients not found within 10-minute observation periods, and guidance is needed for staff balancing hourly checks with more frequent observations.

Concerns summary There is a lack of awareness among employers and employees regarding mental health issues in the workplace, particularly concerning disciplinary processes, suggesting ACAS guidance could be enhanced and better publicised.

Concerns summary Emergency medical dispatchers use confusing questioning to ascertain consciousness, leading to misinterpretation of patient status and missing critical symptoms like a rash or obscured pupils.

Concerns summary Concerns were raised about the lack of formal regulation for non-medical providers of circumcision, a procedure considered surgical with increased infection risk in non-medical settings.

Concerns summary Ineffective security equipment allowed easy access to the station and tracks after operational hours, with individuals able to climb through widely spaced yellow tape.

Concerns summary Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for risk assessment and urgent communication of needed repairs to damaged road signs and markings.

Concerns summary An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of reduced Christmas staffing levels.

Concerns summary The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.

Concerns summary The GP practice failed to inquire about the reason for asthma pump use, and an incomplete care plan system for vulnerable patients meant out-of-hours services lacked full access to critical medical history.