2015

Concerns summary The absence of a pre-operative orthogeriatric review for patients with femoral neck fractures risks inappropriate cemented hemiarthroplasty, potentially leading to fatal bone cement implantation syndrome.

Concerns summary The highway crossover point lacks a deceleration lane and clear signage, forcing westbound traffic to slow dangerously in the outside lane for a right turn, which is not prohibited.

Concerns summary The current junction design encourages dangerous pedestrian crossings over the central reservation due to an unclear, distant designated crossing, posing significant risk.

Concerns summary The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.

Concerns summary The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.

Concerns summary There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.

Concerns summary Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal collision, despite drivers being unable to avoid it.

Concerns summary A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre safety.

Concerns summary A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.

Concerns summary Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a gap in NPSA guidance for lower percentage creams.

Concerns summary The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.

Concerns summary Concerns included unsuitable living accommodation, evident self-neglect, and an inappropriate care package for the deceased, indicating systemic failures in supporting his welfare.

Concerns summary Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.

Concerns summary Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.

Concerns summary Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.

Concerns summary Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.

Concerns summary An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.

Concerns summary Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.

Concerns summary The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.

Concerns summary Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.

Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.

Concerns summary The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.

Concerns summary The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the source of blood, or identify a key head injury, significantly raising the risk of undetected violent crime.

Concerns summary HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.

Concerns summary There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.