2017

Concerns summary An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread ambulance unavailability due to extensive hospital handover delays.

Concerns summary Systemic failures included a lack of risk assessment processes for changing patient needs, poor communication between care home and district nurses, inadequate record-keeping, and non-adherence to pressure relieving strategies.

Concerns summary Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.

Concerns summary Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.

Concerns summary A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.

Concerns summary Ambulance dispatch protocols were not followed, leading to unused resources and breached timescales without escalation. There was also a lack of staff knowledge and a "safety net" system for monitoring dispatches.

Concerns summary There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.

Concerns summary The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines and GPs' knowledge of how to access them.

Concerns summary Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.

Concerns summary The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing and effective care escalation.

Concerns summary The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.

Concerns summary Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.

Concerns summary Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.

Concerns summary An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.

Concerns summary Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without direct psychiatrist assessment, compounded by significant re-assessment delays.

Concerns summary General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially impacting patient outcomes.

Concerns summary Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.

Concerns summary A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.

Concerns summary A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused significant delays.

Concerns summary Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.

Concerns summary Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.

Concerns summary Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.

Concerns summary School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.

Concerns summary The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or specific protocol for critical non-cancerous results.

Concerns summary There was a lack of clear guidance for community nurses on GP involvement and significant systemic failures in sharing patient information and escalating concerns between various healthcare and care provider agencies.