2016

Concerns summary Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.

Concerns summary Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.

Concerns summary Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation with unaware customers.

Concerns summary There was no system for regular medical monitoring of care home residents, with one not seen by a GP for months. Difficulties in arranging assessments for non-attending residents highlighted the need for regular, on-site GP reviews.

Concerns summary Dangerous road conditions near a park entrance are created by the absence of a pedestrian crossing, vehicles obscuring views, and the speed limit, posing significant risks to pedestrians, especially children.

Concerns summary Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.

Concerns summary Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, or capacity assessment for this transfer of care.

Concerns summary Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and overall progression for such a sport.

Concerns summary Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.

Concerns summary Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets or communication devices, and unawareness of rapid hypothermia.

Concerns summary The health centre car park design creates a pedestrian safety hazard, particularly for disabled patients, due to the lack of dedicated crossings or marked safe paths from parking to the entrance.

Concerns summary A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.

Concerns summary Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread and trapping residents.

Concerns summary The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.

Concerns summary Systemic delays plagued patient care, including following up on missed appointments, acting on alerts, and an inadequate protocol for obtaining custom-made grafts, all exacerbated by an incomplete internal investigation.

Concerns summary Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing urgent psychiatric appointments and follow-up after concerning incidents.

Concerns summary The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.

Concerns summary Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.

Concerns summary Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Concerns summary Paramedic foundation training was deficient in ECG interpretation and recognising atypical myocardial infarction symptoms, leading to missed diagnoses of serious cardiac conditions.

Concerns summary A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.

Concerns summary Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.

Concerns summary Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.