2016

Concerns summary A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.

Concerns summary South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing over a footbridge parapet.

Concerns summary The current NHS Pathways triage system lacks a crucial breathing analysis tool for identifying agonal breathing, a concern raised nationally since 2014 with no apparent action.

Concerns summary Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.

Concerns summary Death was caused by hyperammonaemia syndrome, a rare and poorly understood adverse consequence of gastric bypass surgery, with symptoms that are not well known.

Concerns summary E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of awareness among carers and the deceased.

Concerns summary The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.

Concerns summary There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.

Concerns summary A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in some hospitals.

Concerns summary Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both procedures require urgent review.

Concerns summary Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings were obscured by resurfacing and debris.

Concerns summary A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about the deceased's mental health and self-harm history were not escalated to a MASH meeting.

Concerns summary Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.

Concerns summary Care home staff lacked adequate training in safe patient feeding techniques and associated risks, with no refresher courses. Family members also lacked access to essential feeding training.

Concerns summary Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.

Concerns summary An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an absence of clear planning for high call volumes, risking future service failures.

Concerns summary Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.

Concerns summary The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.

Concerns summary Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.

Concerns summary A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching left bend. An advanced warning sign is needed to reduce future fatality risks.

Concerns summary Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns about lifeguard training and information provided to holidaymakers.