2015

Concerns summary (AI summary) The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.

Concerns summary (AI summary) Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from being immediately available to custody nurses.

Concerns summary (AI summary) The unsafe positioning of a zebra crossing too close to a mini-roundabout creates a high-risk junction for pedestrians and drivers, and a simple relocation would significantly improve safety.

Concerns summary (AI summary) The report identifies a lack of staff training in calling emergency services or arranging GP visits, poor observation of residents, failure to report matters to the CQC, and inadequate record-keeping and handovers.

Concerns summary (AI summary) The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.

Concerns summary (AI summary) The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.

Concerns summary (AI 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 (AI summary) The distance between the football touchline and clubhouse fell below FA safety recommendations, placing players at risk of injury or death, with no action taken by the referee.

Concerns summary (AI 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 (AI summary) The report identifies that the deceased appeared to be living in unsuitable accommodation, neglecting himself, and had an inappropriate care package.

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI summary) The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.

Concerns summary (AI 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 (AI summary) The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI summary) An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating evidence before and after on-duty officers arrived, who then failed to secure the scene.