2015

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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.

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI summary) There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.

Concerns summary (AI 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 (AI summary) After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient attempts to contact him or his family, and care was not effectively transferred to the Trafford Crisis Resolution Home Treatment Team.

Concerns summary (AI summary) For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk assessment was ill-informed, not discussed, and poorly documented; for Isobel Griffin, there were issues with key worker allocation, updating risk assessments, clinician reviews, medication management, and ligature points.

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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.