2017

Concerns summary The Cycle Superhighway's road surface has reduced grip, creating a significant hazard that increases the likelihood of road users losing control, especially cyclists at junctions. An urgent review and replacement is needed.

Concerns summary Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.

Concerns summary There was a critical failure to action a psychiatric referral during inpatient care and no follow-up for complex PTSD post-discharge. This highlighted a commissioning gap for suitable services for complex mental health conditions.

Concerns summary Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.

Concerns summary Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance and a failure to routinely use inclinometers, despite known risks from slight gradients.

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

Concerns summary Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.

Concerns summary Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.

Concerns summary A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.

Concerns summary There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.

Concerns summary Inadequate warning signage on the approach to the corner significantly contributed to the accident risk.

Concerns summary The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments after self-harm incidents. There was also an over-reliance on inpatient status as a protective factor and a lack of clarity in observation policies.

Concerns summary Critical delays occurred in arranging mental health appointments, with re-referrals being treated as new, resulting in dangerously long waiting lists and delayed access to care.

Concerns summary The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.

Concerns summary The road layout at the junction was unsafe, with obstructed views of oncoming traffic and an inadequate central reservation, increasing the risk of collisions.

Concerns summary A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to the fatality. The system's influence on driver response requires review.

Concerns summary Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a risk to patient safety.

Concerns summary The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure to properly investigate a patient arrest raised serious safety concerns.

Concerns summary Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a blocked endotracheal tube, compromising patient care.

Concerns summary There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on this and potentially other ships.

Concerns summary Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.

Concerns summary The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.

Concerns summary The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and the student's GP.

Concerns summary There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.

Concerns summary The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.