2016

Concerns summary Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks for visitors.

Concerns summary A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.

Concerns summary There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.

Concerns summary Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted outside of weekdays.

Concerns summary A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.

Concerns summary Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting confidentiality, prevented effective support for a distressed student.

Concerns summary Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations for a special aviation category.

Concerns summary GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical records during admission.

Concerns summary Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were not marked urgent nor accompanied by a phone call.

Concerns summary Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.

Concerns summary A vulnerable service user's agreed care package was not implemented or followed up, as there was no system in place to track the progress of care package implementation.

Concerns summary Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.

Concerns summary Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.

Concerns summary An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific site, exacerbated by sketchy inspection records.

Concerns summary Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating a need to revisit the training manual and methods.

Concerns summary Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.

Concerns summary The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, including "ambulance technicians," largely unregulated, with insufficient checks on mentor suitability for trainees.

Concerns summary Charcoal packaging warnings about indoor use lack prominence and do not explicitly highlight the risk of death from carbon monoxide poisoning.

Concerns summary The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing or verifying crucial safety improvements.

Concerns summary The GP referral form for rapid access endoscopy is limited, potentially leading to the omission of critical past medical history that would assist endoscopists.

Concerns summary Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.

Concerns summary The "legal high" acetylfentanyl, a highly potent opioid, poses significant risks due to users being unaware of its opioid nature, leading to dangerous sedation and respiratory depression.

Concerns summary A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.