2015

Concerns summary Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.

Concerns summary Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

Concerns summary Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has been issued for the defective Minivator 2000 stairlift.

Concerns summary Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on managing risks associated with alcohol withdrawal.

Concerns summary Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.

Concerns summary Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.

Concerns summary Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.

Concerns summary There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged restraint. Additionally, specialized mental health crisis teams and updated patient conveying policies are not nationally implemented.

Concerns summary A pedestrian crossing was dangerously positioned on the apex of a sharp bend, contributing to a fatality. It should be moved to a straight section or controlled by traffic lights.

Concerns summary Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.

Concerns summary The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, inadequate filter lanes, heavy traffic, and road contour, posing risks to cyclists.

Concerns summary The East of England Ambulance Service needs to review training from another trust to improve paramedic decisions on whether to treat patients in the community or transfer them to hospital.

Concerns summary Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.

Concerns summary A seriously substandard, subsided road section poses an immediate danger to motorists, requiring urgent repair, warning signage, and an advisory speed limit. Dangerous posts at the bank's foot also necessitate an Armco barrier.

Concerns summary Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.

Concerns summary Trust staff demonstrated a lack of knowledge and failure to implement key protocols for managing bleeding related to thrombolytic therapy and massive blood loss.

Concerns summary Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.

Concerns summary Concerns were raised about proposed reductions in night-time ward staffing, which risks staff having insufficient capacity to safely care for patients due to increased workloads.

Concerns summary Critical safety procedures were missed, including failure to provide specific aftercare information and incomplete Thromboprophylaxis Risk Assessments, which should have flagged patient risk factors earlier. Discharge notes were also incomplete and checklists unfulfilled.

Concerns summary Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost records.

Concerns summary Pre-operative assessments by junior doctors instead of the consultant led to missed vital information. Operation notes lacked equipment details, and there were insufficient junior doctors, especially at night.

Concerns summary Lack of clearly written conditions for temporary hospital leave, including supervision levels and observation regimes, led to conflicting staff understanding and poor communication with caregivers.

Concerns summary The absence of regulations requiring amber warning beacons on tractors on all roads, not just dual carriageways, may reduce visibility and increase collision risk for other road users.

Concerns summary Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.

Concerns summary A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.