2015

Concerns summary Concerns were raised regarding the ambulance service's policy and training around the Mental Capacity Act, specifically concerning the non-use of force or restraint for patients refusing transport.

Concerns summary The absence of street lighting at a junction, combined with the layout allowing vehicles to drive 'straight through', creates a significant road safety hazard.

Concerns summary Concerns exist regarding the unreliability of INR monitoring systems, including reliance on healthcare assistants for critical clinical information instead of standard protocols. The practice also needs an internal investigation to ensure comprehensive learning among all GPs.

Concerns summary Multiple agencies demonstrated critical failures: unclear protocols for voluntary mental health patients with police, inadequate patient assessment (missing suicide inquiries, collateral history), poor inter-agency communication, and failure to record vital suicidal declarations.

Concerns summary There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.

Concerns summary A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications of evolving diabetes despite a previous raised reading.

Concerns summary Critical failures in the consent process included undocumented risk discussions, lack of patient information, and incomplete or improperly delegated capacity and best interests assessments by untrained staff.

Concerns summary Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.

Concerns summary Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.

Concerns summary Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.

Concerns summary Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.

Concerns summary Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.

Concerns summary Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.

Concerns summary The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect with independent research on consumer safety.

Concerns summary Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.

Concerns summary Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.

Concerns summary Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.

Concerns summary There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.

Concerns summary Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.

Concerns summary Deficient nurse training on diabetes, doctors omitting critical insulin, and a lack of specialist support, consultant cover, and essential equipment were identified. This was compounded by patient transfer delays and under-resourcing for diabetes care.

Concerns summary The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not see or hear approaching high-speed trains, especially if distracted.

Concerns summary Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.

Concerns summary Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may pose a safety risk.

Concerns summary There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm risk, and a lack of senior clinician attendance at discharge reviews.

Concerns summary Non-controlled opiate drugs lacked audit, risking them going unaccounted for. Inconsistent methods for patient observations and radio nurse duties indicated a need for standardized training.