2015

Concerns summary Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.

Concerns summary The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.

Concerns summary Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern communication methods, contributing significantly to his tragic death.

Concerns summary Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.

Concerns summary The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in appropriate medical intervention.

Concerns summary Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.

Concerns summary There are no national guidelines for interpreting antenatal CTG tracings. Additionally, the Trust's Interpreting Policy faced issues with dissemination, application, and applicability, particularly concerning informed consent.

Concerns summary Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, failed inter-team referral, and a prolonged lack of patient contact.

Concerns summary No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.

Concerns summary Despite an action plan stating training was offered to transport services regarding spontaneous haemorrhage, a volunteer driver involved in the incident confirmed receiving no such training whatsoever.

Concerns summary Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, and non-ligature-proof ward doors contributing to self-harm risks.

Concerns summary Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for managing falls in anti-coagulant patients and for escalating concerns.

Concerns summary Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.

Concerns summary An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.

Concerns summary Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.

Concerns summary Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.

Concerns summary Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.

Concerns summary The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.

Concerns summary High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.

Concerns summary The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.

Concerns summary Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.

Concerns summary A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.

Concerns summary Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.

Concerns summary A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic approaching from a particular direction.

Concerns summary Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.