2016

Concerns summary Night-time patient checks lacked specific details on patient condition, and there was unclear guidance for care assistants on escalating health concerns. Both procedures require urgent review.

Concerns summary Drivers lacked adequate warning of a pedestrian crossing near a roundabout due to limited visibility and misleading road features. Additionally, carriageway markings were obscured by resurfacing and debris.

Concerns summary Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.

Concerns summary Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.

Concerns summary Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.

Concerns summary The placenta was not retained after a baby's death, impeding a comprehensive post-mortem examination to determine the cause, such as infection or cord issues.

Concerns summary The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual profiles.

Concerns summary Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.

Concerns summary Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.

Concerns summary Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.

Concerns summary Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and a failure to assess risks to other patients and staff. There were no agreed protocols or senior oversight.

Concerns summary There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.

Concerns summary A presumption in favour of vaginal delivery, partly driven by cost, needs to be re-evaluated to ensure patient safety and appropriate medical decision-making.

Concerns summary Faulty bedrail mechanisms led to instability, and staff provided inappropriate first aid after a patient's fall by moving her without assessing potential head and neck injuries.

Concerns summary Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence of a comprehensive emergency plan for hazardous areas.

Concerns summary Inconsistent and inadequate road signage fails to warn motorists of a critical left-hand bend immediately beyond a hill crest, unlike the opposite direction which has appropriate warnings.

Concerns summary The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village poses a significant risk to locals and visitors, especially families.

Concerns summary A staggered junction, despite meeting design specifications, has a concerning history of multiple fatalities and injury-producing collisions, suggesting inherent safety issues with the junction's design.

Concerns summary The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding risks.

Concerns summary The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked any means of escape for individuals who fell in.

Concerns summary Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.

Concerns summary Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.

Concerns summary Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.

Concerns summary Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.

Concerns summary Insufficient poolside supervision at the hotel due to infrequent patrols and reliance on CCTV monitored by reception staff who are also busy with other tasks, creating a risk of future deaths.