2015

Concerns summary There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.

Concerns summary The 40mph speed restriction is placed after a dangerous road bend, rather than before it, despite multiple incidents, unnecessarily increasing the risk of collisions.

Concerns summary Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.

Concerns summary There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.

Concerns summary A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.

Concerns summary The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.

Concerns summary The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.

Concerns summary Critical construction method variations were undocumented in safety plans, and key personnel lacked understanding of procedures, leading to significant workplace safety risks.

Concerns summary Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment plans.

Concerns summary Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.

Concerns summary Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.

Concerns summary Clinical errors included delayed medication and poor judgment during labor. Systemic failures in incident investigation, note-taking, and providing feedback prevented staff learning and improvement.

Concerns summary Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering early intervention.

Concerns summary Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities and delayed emergency admission.

Concerns summary Significant failures in care home note-keeping, staff training, and communication led to delayed essential care. Procedures were performed unsafely and without adequate supervision or infection control.

Concerns summary Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was unclear.

Concerns summary Brittle asthma, a life-threatening condition, is not covered by medical exemption certificates, causing patients to miss medication due to cost and preventing GPs from escalating care.

Concerns summary Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.

Concerns summary There was an unexplained departure from the patient's management plan during rapid deterioration, crucial blood results were not actioned, and nursing/medical notes were inadequately completed.

Concerns summary Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.

Concerns summary Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact attempts.

Concerns summary Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.

Concerns summary Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.

Concerns summary Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.

Concerns summary The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.