2015

Concerns summary Inappropriate midwifery care by a student and midwife, including insufficient fetal monitoring, misinterpretation of CTG, and failure to escalate, led to an infant's death and raised questions about the hospital's clinical learning environment.

Concerns summary The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.

Concerns summary There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed Amiodarone, particularly concerning liver, thyroid, and respiratory function during the initial treatment period.

Concerns summary Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.

Concerns summary Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.

Concerns summary Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.

Concerns summary A safeguarding concern regarding the deceased's unsuitable accommodation and living conditions was not received or acted upon by a key support stakeholder, preceding a fatal fall.

Concerns summary The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate leadership and medical cover. RMN training also failed to cover pressure sores sufficiently.

Concerns summary An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.

Concerns summary Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling on the bridge.

Concerns summary Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.

Concerns summary An undulation in the road surface caused a loss of vehicle control at higher speeds, posing a significant risk to unsuspecting drivers.

Concerns summary The provided text describes the circumstances of death but does not explicitly state specific concerns or systemic failures identified by the coroner.

Concerns summary Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical information not being acted upon or shared with the requesting GP.

Concerns summary An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, and the MCF Code of Practice lacks smartphone use guidance.

Concerns summary Inadequate signage for safe pedestrian crossing, lack of illuminated signs, and an inappropriate 50 mph speed limit on a complex slip road where driver visibility is limited create significant hazard.

Concerns summary HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns for lone working officers.

Concerns summary A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness guidance, and risk assessment staff were untrained. A disjointed reporting system also impedes accurate heat illness data.

Concerns summary Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.

Concerns summary The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities that Network Rail needs to address.

Concerns summary The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying this as a risk.

Concerns summary Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.

Concerns summary Inadequate national guidance and audit procedures prevent healthcare providers from consistently advising pregnant women about whooping cough vaccination. Poor communication links between antenatal healthcare providers also pose risks.

Concerns summary The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.

Concerns summary Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, jeopardising vulnerable persons.