2015

Concerns summary A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are no warning signs for pedestrians or motorists regarding this dangerous crossing point.

Concerns summary Motorcross events do not mandate body protection for competitors, which could prevent fatal injuries.

Concerns summary The provided text is incomplete and does not contain specific concerns.

Concerns summary Emergency Department doctors and staff lack a digital system to support their work.

Concerns summary A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill health.

Concerns summary An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.

Concerns summary A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.

Concerns summary Senior care staff lacked awareness of a resident's life-threatening condition and medication, failing to appreciate the urgency of re-ordering supplies. Care home records also lacked critical information about the condition.

Concerns summary The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental Health Liaison Team also lacked a process to identify patients awaiting assessment.

Concerns summary A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.

Concerns summary Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.

Concerns summary Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.

Concerns summary The bath time observation policy for epileptic patients is inadequate, with concerns about the effectiveness of sound-only monitoring and potential staff distraction. The RIO system also lacks sufficient fields for comprehensive epilepsy information, hindering staff access.

Concerns summary A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.

Concerns summary Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight patients was also easily missed due to poor visibility on posters.

Concerns summary A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major roundabout lacks a pedestrian crossing. Other local roads have adopted lower limits for safety.

Concerns summary Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across repeated hospital visits.

Concerns summary Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of increased fire-door closing times in hospitals.

Concerns summary A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.

Concerns summary HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.

Concerns summary Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.

Concerns summary Neither public participants nor paid hunt staff are required to wear protective headgear that complies with recognised safety standards during hunting events, posing a significant injury risk.

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.