2015

Concerns summary Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of Crisis Resolution Home Treatment Teams as a barrier to inpatient bed access.

Concerns summary Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may pose a safety risk.

Concerns summary Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due to increased workloads.

Concerns summary Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. Discharge notes were also incomplete and checklists unfulfilled.

Concerns summary Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost records.

Concerns summary Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, especially at night.

Concerns summary Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.

Concerns summary The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may reduce visibility and increase collision risk for other road users.

Concerns summary There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm risk, and a lack of senior clinician attendance at discharge reviews.

Concerns summary Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.

Concerns summary Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.

Concerns summary Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.

Concerns summary A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.

Concerns summary Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.

Concerns summary There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of apparatus function and user competence before patient discharge.

Concerns summary An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, up-to-date system.

Concerns summary A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.

Concerns summary A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.

Concerns summary Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel treatments and training failures.

Concerns summary There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.

Concerns summary Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.

Concerns summary Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.

Concerns summary The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.

Concerns summary Severe hospital understaffing led to a single qualified nurse managing 16 patients, resulting in missed observations and policy-breaching drug rounds. Additionally, the hospital lacks adequate out-of-hours doctor cover, relying on paramedics.

Concerns summary The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member on every shift. Furthermore, first aid training for health support workers, especially for dependent service users, was insufficient.