2016

Concerns summary There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological observations.

Concerns summary Emergency Department staffing levels were inadequate, preventing the implementation of national and local policies for the timely and effective treatment of suspected sepsis.

Concerns summary Despite a history of multiple accidents and impending junction improvements, the maximum speed limit for vehicles approaching the hazardous junction was not reviewed, maintaining a safety risk.

Concerns summary Prolonged occupational exposure to white spirit, involving both direct skin contact and vapour inhalation over 13 years, caused the employee's death.

Concerns summary There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance on interpreting snoring, the impact of intoxication, and effective information sharing.

Concerns summary Inadequate discharge risk assessment failed to consider a mobility-impaired, incontinent dementia patient's specific home environment and care needs, contributing to a fall and subsequent death.

Concerns summary Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before priority categorization.

Concerns summary Motorcycles frequently use residential pathways at excessive speeds, posing a significant and constant risk of death to pedestrians, especially children and vulnerable individuals.

Concerns summary Road markings on the A49 Tarporley Road, specifically the ghost island, lane dividers, and right turn arrows, are significantly worn and indistinct, posing a safety risk.

Concerns summary Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for staff on pH testing and syringe hygiene compromised care for a child in the community.

Concerns summary Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.

Concerns summary Systemic failures included non-compliance with sepsis protocols, inadequate diabetic patient monitoring, issues with medication administration, and poor record-keeping, leading to fragmented and unreliable care.

Concerns summary Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.

Concerns summary The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.

Concerns summary Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.

Concerns summary The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.

Concerns summary An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.

Concerns summary Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and poor documentation.

Concerns summary Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the risk of harm.

Concerns summary The RSSB Rule Book inadequately permits stopping trains only when a person threatens damage to the train, not when a person is in danger from an approaching train.

Concerns On the 22/12/2016 opened an inquest into the death of Keith William Rushton who, at the date of his death was 78 years old. The inquest was resumed and concluded on 31/8/2016. Ifound that the cause...

Concerns summary A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.

Concerns summary Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in cabs put workers at risk. Training for risk assessment and health and safety awareness was inadequate.

Concerns summary A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.

Concerns summary Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.