2016

Concerns summary A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.

Concerns summary No protocol or guidance exists for Mental Health Nurses regarding doctor referral decisions when discharging self-harm patients, particularly those on a Community Treatment Order, creating a significant risk.

Concerns summary A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.

Concerns summary Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.

Concerns summary The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.

Concerns summary The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff during a theatre procedure.

Concerns summary A lorry driver's elevated cab position prevented seeing a pedestrian crossing directly in front of the vehicle, resulting in a fatal collision and highlighting pedestrian visibility issues for large vehicles.

Concerns summary Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially fatal risk to naive users due to the high total dosage.

Concerns summary The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.

Concerns summary The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.

Concerns summary Multiple systemic failures included inadequate falls risk assessment, missing neurological charts, poor communication between medical and nursing staff, immediate shredding of handover sheets, and insufficient incident reporting.

Concerns summary The Fire and Rescue Service failed to provide effective occupational health support, assigning extra duties to a distressed employee after a colleague's death, indicating a general lack of support for staff in stressful situations.

Concerns summary Chamfered kerbstones and the absence of a protective Armco barrier on a central reservation were identified as potential factors contributing to a vehicle overturning and posing increased danger to road users.

Concerns summary Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.

Concerns summary A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.

Concerns summary Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.

Concerns summary Safety recommendations from a British Transport Police report to restrict public access and enhance safety at a railway bridge remained unaddressed by the time of the inquest.

Concerns summary Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.

Concerns summary Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.

Concerns summary Intermediate care suffered from unclear management standards, inadequate staffing, staff failing to understand notes, and a lack of proper handover from the hospital. Vital records were also unavailable.

Concerns summary The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in a diabetic.

Concerns summary Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.

Concerns summary A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.

Concerns summary The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.

Concerns summary Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.