2016

Concerns summary The use of two separate patient note systems caused confusion and errors, and repeated denials of hospital appointments led to a significantly delayed diagnosis of a critical abdominal issue.

Concerns summary The withdrawal of urgent endoscopy services at a hospital, despite available resources, forces critically ill patients to be transported, causing unnecessary discomfort and potentially aggravating their conditions.

Concerns summary No specific concerns are detailed in the provided text, which refers only to the jury's determination.

Concerns summary Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate prescribing and unclear, scanty GP electronic notes contributed to unsafe care.

Concerns summary There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.

Concerns summary Older large goods vehicles, not mandated to have Class VI "cyclops" mirrors, have a dangerous blind spot directly in front, making pedestrians invisible to the driver and increasing collision risk.

Concerns summary Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource planning for seasonal population increases.

Concerns summary Systemic failures in care provision include support workers lacking keys, leaving residents unsupervised, and inadequate staffing levels, training, and procedural adherence regarding care plans and risk management.

Concerns summary Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.

Concerns summary Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.

Concerns summary A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.

Concerns summary The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.

Concerns summary A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.

Concerns summary Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.

Concerns summary Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.

Concerns summary Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.

Concerns summary The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.

Concerns summary Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.

Concerns summary Inadequate planning policies for tall buildings around the London Heliport fail to ensure safety, lacking in-depth consultation with the Heliport and official safeguarding measures, despite clear risks to flight paths.

Concerns summary Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.