2015

Concerns summary A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.

Concerns summary The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.

Concerns summary Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.

Concerns summary A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to highlight uncollected prescriptions, especially for dependent patients.

Concerns summary Multiple agencies demonstrated critical failures: unclear protocols for voluntary mental health patients with police, inadequate patient assessment (missing suicide inquiries, collateral history), poor inter-agency communication, and failure to record vital suicidal declarations.

Concerns summary The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.

Concerns summary There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.

Concerns summary Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.

Concerns summary There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.

Concerns summary The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.

Concerns summary National police driver training for night-time operations lacks a compulsory practical in-car element, potentially compromising officer safety and response effectiveness.

Concerns summary The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.

Concerns summary The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.

Concerns summary Revised training for community hospital staff lacks provision for obtaining emergency expert medical advice from acute hospitals, potentially delaying critical guidance in urgent situations.

Concerns summary Systemic failure in adhering to drug administration guidelines, including inadequate blood pressure monitoring, poor record-keeping, and insufficient staff training and awareness regarding signs of patient deterioration for patients on Methadone/Buprenorphine.

Concerns summary The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for children.

Concerns summary Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.

Concerns summary A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications of evolving diabetes despite a previous raised reading.

Concerns summary Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly delegated capacity and best interests assessments by untrained staff.

Concerns summary An inexperienced midwife was unsupported during delivery without prior resuscitation training, highlighting flaws in midwife allocation and the 'Supervisors of Midwives' support system.

Concerns summary The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.

Concerns summary Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.

Concerns summary Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.

Concerns summary A crucial towpath gate, intended to be locked during high river levels, was open due to the absence of an effective notification system between agencies, posing ongoing flood safety risks.

Concerns summary A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.