2016

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 Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.

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 Neurology Ward Administrators were unaware of their responsibility to book follow-up appointments, resulting in a systemic failure to schedule critical post-discharge care for many patients.

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 summary Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.

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 Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.

Concerns summary There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to future deaths.

Concerns summary Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care beds.

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 Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in safety checks.

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 Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.

Concerns summary Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.

Concerns summary The provided text is incomplete and does not detail specific concerns.

Concerns summary There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.

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.

Concerns summary Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records further hindered investigation into patient care.

Concerns summary Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices poses a safety risk.

Concerns summary The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.

Concerns summary The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.

Concerns summary Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.

Concerns summary A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.