2017

Concerns summary Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.

Concerns summary A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.

Concerns summary The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.

Concerns summary Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.

Concerns summary The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an unacceptable risk for drivers encountering stationary vehicles at speed.

Concerns summary Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.

Concerns summary A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.

Concerns summary The absence of safety sensors on a chair mechanism led to a crushing injury, as it failed to detect a foot's presence and prevent operation.

Concerns summary The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for medical assistance.

Concerns summary Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.

Concerns summary Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.

Concerns summary A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.

Concerns summary Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.

Concerns summary A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.

Concerns summary Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.

Concerns summary Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical diagnostic investigations.

Concerns summary Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for call handlers.

Concerns summary The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.

Concerns summary Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed opportunities for timely life-saving treatment.

Concerns summary The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.

Concerns summary A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.

Concerns On 23"' June 2016 an Investigation was commenced into the death of Dianne Jane MACRAE. The investigation concluded by way of inquest on 17"^ and IS'" May 2017. The medical cause of death was:- 1a)...

Concerns summary A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.

Concerns summary Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.

Concerns summary The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing risk to drivers.