2016

Concerns summary An undetected foreign body airway obstruction could inhibit the use of a supraglottic airway, suggesting laryngoscopy should be a prerequisite for SGA insertion.

Concerns summary Call handlers required refresher training on contacting resident managers during emergencies and lacked a protocol for raising immediate concerns when unable to get a response from emergency call system users.

Concerns summary Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.

Concerns summary Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.

Concerns summary A patient died due to a drain, and a scan potentially could have reduced this risk, indicating a need for further consideration of policy changes regarding such procedures.

Concerns summary Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified by the Trust's internal investigation.

Concerns summary After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.

Concerns summary Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.

Concerns summary Hospital practice condoned nurse-led post-operative reviews and patient discharges without adequate medical overview, even for unwell patients, potentially leading to missed diagnoses like pneumonia.

Concerns summary Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.

Concerns summary A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk potentially widespread in GP practices.

Concerns summary No specific concerns are detailed in the provided text.

Concerns summary UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate international data sharing, "watch list" management, and potential loss of Europol access post-Brexit.

Concerns summary Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.

Concerns summary Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.

Concerns summary A patient was prescribed fluticasone, increasing pneumonia risk without benefit due to a non-raised eosinophil count. The coroner recommends reviewing inhaled steroid use in similar patient populations.

Concerns summary No specific concerns are detailed in the provided text.

Concerns summary Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.

Concerns summary Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.

Concerns summary Systemic failures included inadequate antenatal GBS screening and prophylaxis, alongside hospital issues such as poor communication, protocol non-adherence, missed examinations, incorrect early warning scores, and insufficient staff training.

Concerns summary Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.

Concerns summary Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.

Concerns summary Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving at-risk individuals unmonitored.

Concerns summary A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically from the patient and an uninformed spouse.

Concerns summary A paediatric doctor made an erroneous extubation decision without consulting a consultant. There were also delays in contacting a tertiary unit and an inadequate handover for the premature baby's arrival.