2016

Concerns summary Hospital staff failed to maintain clear radiology records, misidentified a patient, and lacked training to recognise blocked bowel symptoms. Poor inter-departmental communication and treating the least serious diagnosis first were also issues.

Concerns summary No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.

Concerns summary Concerns include inadequate security of railway platform barriers and a lack of monitoring for a passenger asleep on the platform for an extended period at a 24-hour staffed station.

Concerns summary Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident scene and increased risk of death.

Concerns summary The provided concerns text is incomplete and does not clearly articulate specific safety issues or systemic failures regarding Kirsty Childs' death.

Concerns summary Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.

Concerns summary A railway crossing point was in a poor state, with a section standing proud of the track, presenting a significant tripping hazard for users.

Concerns summary Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.

Concerns summary An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.

Concerns summary Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to unmitigated severe pain at discharge. Audit plans also failed to address general severe pain cases.

Concerns summary Concerns included frequent, unnecessary ward transfers, poor medical record-keeping, care by unqualified staff, and inaccurate anticoagulant dosing due to weight recording issues. Equipment shortages and non-sterile surgical kits also caused dangerous operational delays and increased DVT risk.

Concerns summary There was no evidence of a system to ensure daily GP messages were consistently countersigned and acted upon by general practitioners.

Concerns summary Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back was prematurely closed and a joint investigation has not occurred.

Concerns summary The accumulation of wet soil and sandy deposits on the A25 Sheer Road, near a sandpit entrance, creates a road hazard for drivers.

Concerns summary Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.

Concerns summary Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and poor communication during transfers. These systemic failures and inadequate ACCT procedures contributed to the death.

Concerns summary Missed opportunities to investigate abnormal ECG and tachycardia led to delayed diagnosis. Systemic failures in information recording and transmission, coupled with unconsidered medication contraindications, contributed to inadequate care.

Concerns summary The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan on discharge and deficiencies in the internal investigation.

Concerns summary Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up on referrals. Additionally, no internal investigation was conducted into the death.

Concerns summary An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.

Concerns summary Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.

Concerns summary The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis and treatment.

Concerns summary Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.

Concerns summary A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying crucial diagnosis and treatment.

Concerns summary HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.