2016

Concerns summary Repeated requests for transfer to a specialist gastroenterology ward were not actioned, highlighting a systemic failure in implementing consultant-recommended patient transfers.

Concerns summary Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital treatments.

Concerns summary National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.

Concerns summary Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.

Concerns summary The Trust's action plan is inadequate, lacking specific detail, supporting evidence, and requiring a far more rigorous approach to prevent future deaths.

Concerns summary The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.

Concerns summary The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.

Concerns summary Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.

Concerns summary Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.

Concerns summary A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.

Concerns summary A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.

Concerns summary A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.

Concerns summary Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of his critical mental state.

Concerns summary Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.

Concerns summary Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family information on admission.

Concerns summary Persistent standing water and water flow across a specific carriageway section contributed to numerous past collisions, posing an ongoing danger to road users, especially during heavy rain.

Concerns summary A regulatory loophole allows individuals with criminal convictions to become "Nominated Individuals" for care homes without independent suitability assessment, particularly in small, family-owned companies.

Concerns summary There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective use during cardiac arrest.

Concerns summary Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health assessment information not being effectively shared or accessed.

Concerns summary The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." There were also significant delays for HGVs attempting to turn safely.

Concerns summary Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes for vulnerable patients.

Concerns summary The report text does not detail specific concerns.

Concerns summary A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme Approach and NICE guidelines were not followed.

Concerns summary The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised practice, poses a significant risk to patient safety.

Concerns summary There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review to protect playing children.