2015

Concerns summary Delayed diagnosis of a caecum perforation due to multiple systemic failures, including overlooked warning signs, delayed CT scans, inadequate interpretation of radiology findings, and improper use of early warning scores for sepsis.

Concerns summary Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.

Concerns summary Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in duty of care and health monitoring.

Concerns summary Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of vital safety history for vulnerable individuals.

Concerns summary No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.

Concerns summary A pedestrian stile leads directly onto a busy dual carriageway with a national speed limit, and there are no warning signs for pedestrians or motorists regarding this dangerous crossing point.

Concerns summary The provided text is incomplete and does not contain specific concerns.

Concerns summary Emergency Department doctors and staff lack a digital system to support their work.

Concerns summary A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.

Concerns summary A paramedic failed to effectively use the sepsis screening tool, indicating a need for better training for ambulance staff on its use and appropriate patient conveyance to hospital.

Concerns summary Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.

Concerns summary A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.

Concerns summary A 60mph speed limit on a road with residential properties and busy amenities is inappropriate, and a major roundabout lacks a pedestrian crossing. Other local roads have adopted lower limits for safety.

Concerns summary Concerns were raised that the child's asthma care focused only on acute presentations, failing to address the underlying chronic condition holistically across repeated hospital visits.

Concerns summary A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.

Concerns summary Defects in the pull-cord alarm system were unaddressed, residents were responsible for smoke detector maintenance, and smoke detectors were not linked to the emergency control room, delaying fire alerts.

Concerns summary Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.

Concerns summary A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.

Concerns summary Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.

Concerns summary A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to safe home leave procedures.

Concerns summary There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for a post-natal patient.

Concerns summary The quality of street lighting at the incident location was poor and may have contributed to the event.

Concerns summary Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.

Concerns summary Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.

Concerns summary Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.