2017

Concerns summary A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.

Concerns summary Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.

Concerns summary There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.

Concerns summary The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.

Concerns summary A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.

Concerns summary The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.

Concerns summary The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for the procedure or alternative feeding methods.

Concerns summary There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.

Concerns summary A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.

Concerns summary Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Concerns summary A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.

Concerns summary Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.

Concerns summary An illuminated advertising board and overhanging tree canopies dangerously obstructed visibility for both pedestrians and drivers. Reduced tree lopping in the area was also a concern.

Concerns summary A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.

Concerns summary A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.

Concerns summary There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.

Concerns summary Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.

Concerns summary There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.

Concerns summary The system over-relied on individuals proactively managing their rehabilitation post-detoxification. Concerns included a lack of fixed appointments, follow-up calls, and limited availability of an alcohol liaison nurse post-discharge.

Concerns summary There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.

Concerns summary A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.

Concerns summary Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.

Concerns summary There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with a specified ratio.

Concerns summary A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition regarding the absconding risk when allowing a detained patient leave.

Concerns summary A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.