2015

Concerns summary Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.

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 Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.

Concerns summary A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.

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 Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.

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 There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are not informed.

Concerns summary A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to safe home leave procedures.

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 There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for a post-natal patient.

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 The quality of street lighting at the incident location was poor and may have contributed to the event.

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 A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.

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 Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.

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 Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.