2015

Concerns summary Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved in the incident confirmed receiving no such training whatsoever.

Concerns summary Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, and non-ligature-proof ward doors contributing to self-harm risks.

Concerns summary The design of an outward-opening toilet cubicle door led to two identical head injuries within six weeks, indicating a systemic risk, especially as it contradicts disabled toilet design guidance.

Concerns summary Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS score were identified.

Concerns summary Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.

Concerns summary There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.

Concerns summary Inadequate and poorly located warning signs failed to highlight the dangers of a particularly deep pool with strong currents in the River Wear, leaving river path users unaware.

Concerns summary Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for managing falls in anti-coagulant patients and for escalating concerns.

Concerns summary Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.

Concerns summary Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Concerns summary An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.

Concerns summary Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.

Concerns summary Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.

Concerns summary An acknowledged dangerous bus stop on a busy road has seen no action taken on long-standing concerns and feasibility studies for safety improvements, despite previous warnings.

Concerns summary Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to resource limitations.

Concerns summary Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.

Concerns summary Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.

Concerns summary A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.

Concerns summary Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and there are no warning signs to inform them.

Concerns summary The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.

Concerns summary The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Concerns summary PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.

Concerns summary Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.

Concerns summary There was an unacceptable three-month delay in conducting a Best Interests Assessment for a Deprivation of Liberty Safeguarding Authorisation, leaving a vulnerable patient unassessed.

Concerns summary Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.