2016

Concerns summary Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed responses. The proposed solution relies on staff goodwill and doesn't fully mitigate risks.

Concerns summary A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.

Concerns summary Unsupervised liquid-absorbing crystals, mistaken for consumables, caused a patient's death. The risks of these sachets are not fully understood, necessitating improved risk assessment, staff awareness, and training.

Concerns summary Easy access to the railway line through inadequate fencing and an access gate poses a risk, and a recommended review of these security measures has not been carried out.

Concerns summary Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.

Concerns summary The hospital failed to ensure an unwell patient engaged with crucial group therapy, despite it being the reason for admission, leading to isolation and a suboptimal therapeutic environment.

Concerns summary The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance arrangements.

Concerns summary Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving conditions, despite the drainage being considered operative.

Concerns summary The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.

Concerns summary Critical failures in managing informal patient leave, including lack of staff policy knowledge, inadequate risk assessment updates, and severe delays in responding to a patient's absence, contributed to significant safety concerns.

Concerns summary Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.

Concerns summary Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.

Concerns summary Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.