2016

Concerns summary A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.

Concerns summary Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.

Concerns summary Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for children playing near the water.

Concerns summary Incomplete medical records, an agency nurse's failure to correctly apply and escalate patient conditions using the NEWS scoring system, and inadequate monitoring of agency staff training.

Concerns summary Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.

Concerns summary Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.

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 Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.

Concerns summary Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.

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 Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.

Concerns summary Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.

Concerns summary Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.

Concerns summary Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.

Concerns summary Foetal heart rate was not monitored, midwifery guidelines for CTG assessment and obstetric review were not followed, and a midwife lacked recent experience for an essential procedure.

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 Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.

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.