2015

Concerns summary Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.

Concerns summary Systemic failures include a lack of central register for hotel safety data, poor tour operator collaboration, insufficient carbon monoxide awareness, and delegation of critical health and safety checks to inexperienced staff.

Concerns summary Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.

Concerns summary There's a concern about ensuring healthcare professionals are adequately trained in resuscitation and can respond appropriately to patient collapse.

Concerns summary A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates an ongoing risk of avoidable deaths.

Concerns summary Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.

Concerns summary Street lighting was switched off on a dark night, significantly reducing pedestrian visibility and contributing to a fatal collision, despite drivers being unable to avoid it.

Concerns summary The road layout has insufficient segregation for mixed traffic, with a confusing contra-flow cycle lane and unclear signage, creating a dangerous environment compounded by weak guidance on pedestrian use of cycle paths.

Concerns summary A gym lacked immediate problem recognition, adequate resuscitation, risk assessments for users, qualified first aiders, and formal national guidance on fitness centre safety.

Concerns summary Rescue was delayed due to the standby diver being unable to locate a critical harness c-clip, as pre-dive protocol checks do not include verifying its accessibility.

Concerns summary Care staff lacked training in PEG feeding, including patient mobility, leading to an incident of vomiting that was not reported or investigated, indicating systemic failures in training and incident management.

Concerns summary Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.

Concerns summary A dangerous road junction has blind spots and limited driver visibility, creating a "pinch point" for large vehicles and putting pedestrians at risk, compounded by potentially insufficient crossing times.

Concerns summary Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse victims, relying inappropriately on presentation.

Concerns summary A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT reviews, risking missed critical information.

Concerns summary Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.

Concerns summary A cadet training site lacked defibrillators and AED-trained first aiders, with challenging emergency access. There were also ineffective communication checks between staff and cadets at night.

Concerns summary Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.

Concerns summary Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising serious conditions and safeguarding patients.

Concerns summary Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for regular, confirmed training.

Concerns summary There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.

Concerns summary A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly balance his acute needs and risks against restrictions.

Concerns summary The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health resources in the area.

Concerns summary The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student problems.

Concerns 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.