2017

Concerns summary A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking detrimental effects on treatment.

Concerns summary Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.

Concerns summary The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet use, creating an unsafe environment.

Concerns summary Persistent, unaddressed systemic failures at the Trust include poor communication, inadequate supervision, incorrect early warning scores, and delayed action on patient deterioration, compounded by challenges from split-site operations.

Concerns summary Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.

Concerns summary There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing delivery services about potential dangers, and no policy preventing drivers from entering without prior contact.

Concerns summary A Community Matron's failure to take physiological readings and incorrectly assess consent for an X-ray in a patient with severe dementia led to a two-week delay in diagnosing a fractured hip.

Concerns summary A lack of awareness regarding the safety-critical role and vulnerability of ladder spigots poses significant health and safety risks due to potential inadvertent shearing.

Concerns summary There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable homeless individuals on campsites, and an unclear statutory duty to house them.

Concerns summary Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.

Concerns summary The report indicates a risk of future deaths unless action is taken, but no specific concerns were detailed in the provided text.

Concerns summary Inconsistent police training and guidance regarding PAVA spray use and forcible mouth searches for detained persons with objects in their mouths, conflicting with FFLM recommendations, indicates a systemic failure to implement past lessons.

Concerns summary The junction's design creates a significant "blind spot" for turning drivers, severely limiting their view of pedestrians, raising safety concerns during crossings.

Concerns summary Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.

Concerns summary The absence of rumble strips on double white lines at a merging carriageway increases the risk of vehicles inadvertently straying into oncoming traffic, particularly where visibility is inhibited.

Concerns summary A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and drivers to cut corners, posing significant collision risks.

Concerns summary The report describes the circumstances of a death from overdose but does not detail specific coroner's concerns regarding systemic failures or future death risks.

Concerns summary An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family about the fatal risks of missed medication and follow-up contact.

Concerns summary The road's narrow, unlit, and unkerbed characteristics, bordered by hedgerows, make the 70 mph speed limit unsafe, with experts stating speeds above 50 mph pose significant risks.

Concerns summary There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.

Concerns summary Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, stemming from a lack of accountability in the school's construction.

Concerns summary Multiple collisions at a junction highlight the need for a reduced speed limit on the A36, improved road signage, and better carriageway markings to enhance driver safety.

Concerns summary Midwives and junior obstetricians demonstrated a critical lack of skill in interpreting abnormal cardiotocograph (CTG) traces. This highlights a systemic failure in CTG training and a need for mandatory competency testing for intrapartum care.

Concerns summary No specific concerns regarding future deaths were detailed in the provided text, only contact information.

Concerns summary The junction's design is inherently dangerous, allowing left-turning vehicles to cross straight-ahead traffic and lacking clear road signage to warn users of potential conflict, especially for cyclists.