2016

Concerns summary Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or a mental capacity assessment.

Concerns summary Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.

Concerns summary Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.

Concerns summary The junction has an extremely restricted view of traffic due to its layout and a solid wall. Furthermore, signage is limited and confusing, with speed limit signs visible too early.

Concerns summary Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.

Concerns summary A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline nurses unable to safely care for vulnerable patients.

Concerns summary Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.

Concerns summary Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.

Concerns summary Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation with unaware customers.

Concerns summary There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments for non-attending residents highlighted the need for regular, on-site GP reviews.

Concerns summary Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.

Concerns summary Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed limit, posing significant risks to pedestrians, especially children.

Concerns summary This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists are insufficient, and no standardized risk classification system for swimming is in place.

Concerns summary Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.

Concerns summary Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.

Concerns summary The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.

Concerns summary Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, or capacity assessment for this transfer of care.

Concerns summary Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and overall progression for such a sport.

Concerns summary A potential training deficit exists regarding supporting nicotine-addicted and suicidal patients through withdrawal, which could compromise their care in a hospital setting with a non-smoking policy.

Concerns summary Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.

Concerns summary Inadequate treatment of pressure ulcers can lead to severe complications like osteomyelitis and sepsis in the elderly, compounded by an insufficient number of Tissue Viability Nurses in healthcare.

Concerns summary Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets or communication devices, and unawareness of rapid hypothermia.

Concerns summary The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.

Concerns summary The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings or marked safe paths from parking to the entrance.