2016

Concerns summary Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.

Concerns summary Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.

Concerns summary Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.

Concerns summary Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.

Concerns summary Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.

Concerns summary Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.

Concerns summary There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.

Concerns summary Medical professionals and implant manufacturers lack awareness that a rare toxin causing sepsis can suppress typical inflammation signs, potentially delaying diagnosis and treatment for patients with breast implants.

Concerns summary A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.

Concerns summary The BIPAP machine's battery alarm is visually obscured and lacks a distinct sound, hindering staff recognition of critical power loss due to inadequate training. The ward lacked isolated power supply, and there was no system to detect mains power failure.

Concerns summary Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.

Concerns summary Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and poor weekend/Bank Holiday healthcare access also posed significant risks.

Concerns summary No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating a significant risk.

Concerns summary A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.

Concerns summary Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.

Concerns summary The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.

Concerns summary The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff during a theatre procedure.

Concerns summary There are no life rings installed at Lock 19 on the Calder Canal, creating a clear risk of future deaths from drowning.

Concerns summary A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting in a fatal collision and highlighting pedestrian visibility issues for large vehicles.

Concerns summary Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially fatal risk to naive users due to the high total dosage.

Concerns summary The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.

Concerns summary A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, creating a risk of future deaths.

Concerns summary A road bend lacks adequate deviation markings, a tree trunk near the carriageway edge endangers road users, and a path's slippery surface could cause walkers to fall into the road.

Concerns summary The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.

Concerns summary A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined with unclear information resources, risks uncontrolled bleeding.