2016

Concerns summary Hospital policy restricts doctors to issuing only hospital-specific prescriptions. This, combined with a non-24-hour pharmacy, prevents A&E patients from accessing critical medication outside of pharmacy hours.

Concerns summary Misplacement of a central venous line into an artery highlighted a need for wider promulgation of improved insertion and removal procedures to reduce deaths.

Concerns summary Ineffective missing persons searches were hampered by reliance on volunteer mapping systems rather than a police stand-alone system, and the lack of tracking devices for searchers.

Concerns summary Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.

Concerns summary The NHS Trust's lack of routine weekend CT scan facilities led to a critical delay in an urgent scan, proving too late for the patient.

Concerns summary Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

Concerns summary Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.

Concerns summary Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.

Concerns summary Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.

Concerns summary A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.

Concerns summary There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.

Concerns summary Urgent diagnostic tests were critically delayed over a weekend due to the hospital lacking a robust system for ensuring timely imaging, particularly for patients admitted outside of weekdays.

Concerns summary A critical lack of liaison between tertiary and local hospitals resulted in no agreed delivery plan for a baby with identified heart anomalies, increasing risks for mother and child.

Concerns summary Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations for a special aviation category.

Concerns summary Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were not marked urgent nor accompanied by a phone call.

Concerns summary Multiple communication failures, poorly completed observation charts, lack of a paediatric sepsis protocol, and ineffective dissemination of medical updates contributed to systemic care failures.

Concerns summary A vulnerable service user's agreed care package was not implemented or followed up, as there was no system in place to track the progress of care package implementation.

Concerns summary Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.

Concerns summary Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.

Concerns summary An unsuitable wooden shed was licensed for fireworks storage, containing other combustibles and having deficient licensing that failed to specify types or designate a specific site, exacerbated by sketchy inspection records.

Concerns summary Call handlers failed to use medical history to inform ambulance services and were not trained to report changes in patient presentation, indicating a need to revisit the training manual and methods.

Concerns summary Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.

Concerns summary The regulation of private medical companies at events is inadequate, creating false security and leaving event medical provision, including "ambulance technicians," largely unregulated, with insufficient checks on mentor suitability for trainees.