2015

Concerns summary Nursing records, assessments, and discharge summaries were consistently incomplete and inaccurate, demonstrating no material improvement despite ongoing audits and posing recurrent patient safety risks.

Concerns summary The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.

Concerns summary A pressure sore management plan was poorly followed, with falsified records, missed turns, and inadequately trained staff in record-keeping and mattress management. Referrals to specialists were also delayed.

Concerns summary Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of injury or death.

Concerns summary Critical specialist eating disorder services for children lacked long-term funding and inpatient bed provision. Insufficient funding for school nurses caused poor communication between mental health and education systems.

Concerns summary Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.

Concerns summary Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.

Concerns summary Prison officers were either unaware of or failed to follow instructions requiring them to elicit a response from prisoners upon cell unlocking. They also did not consistently receive or read crucial Prison Service Orders.

Concerns summary A vulnerable patient was inappropriately placed in a residential care home without nursing care or staff trained for her needs. A lack of formal guidance for agencies led to unsuitable placements for vulnerable individuals.

Concerns summary Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.

Concerns summary Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.

Concerns summary The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.

Concerns summary A patient was discharged home after a head injury without assessing their home circumstances or documenting discharge risk factors, violating NICE guidelines on patient observation.

Concerns summary Senior management failed to act on previous PFD reports concerning inadequate physical healthcare, including missing consultant physician visits and inconsistent glucose testing, for mental health patients. This indicates a systemic failure to implement crucial safety recommendations and ensure appropriate medical oversight.

Concerns summary A lack of mandatory system for residential homes to seek Social Services advice before discharging residents creates a serious risk that discharged individuals will not have appropriate safety and welfare arrangements in place.

Concerns summary The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the source of blood, or identify a key head injury, significantly raising the risk of undetected violent crime.

Concerns summary A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.

Concerns summary There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked crucial evidence, and did not consider potential third-party involvement, compromising the investigation.

Concerns summary An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating evidence before and after on-duty officers arrived, who then failed to secure the scene.

Concerns summary Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.

Concerns summary Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke as an immediate emergency, risking critical treatment windows.

Concerns summary The City Council's highway inspection system and asset database were ineffective, failing to identify a missing road sign and defective lighting for years, significantly hindering remedial action and posing a risk to road safety.

Concerns summary Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.

Concerns summary Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight cardiac arrest despite such equipment being available and simple to operate.

Concerns summary HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.