2017

Concerns summary Agency staff lacked adequate training in proper documentation, monitoring clinical condition changes, and urgently obtaining medical assistance, raising concerns about patient safety.

Concerns summary A lack of dedicated cycle lanes on a busy road, coupled with an obstructed footpath and a hazardous kerb dip, created an unsafe environment for cyclists.

Concerns summary Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased risk.

Concerns summary The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured visibility contributing to safety risks.

Concerns summary Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.

Concerns summary A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.

Concerns summary Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.

Concerns summary A poorly informed decision to discharge a patient with no improvement, without doctor review, led to a failed discharge that seriously compromised the patient's health.

Concerns summary Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access to the tracks, posing a serious safety risk.

Concerns summary Multiple deaths from misplaced nasogastric tubes highlight systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."

Concerns summary Repeated deaths from misplaced nasogastric tubes exposed systemic failures, including staff non-compliance with policy, inadequate training and audits, and a failure to learn from previous "Never Events."

Concerns summary Absence of a clear pathway for life-saving neurosurgery referral, issues with diagnostic imaging, and insufficient input from stroke physicians were identified as critical concerns. A lack of defined protocols risked delayed treatment for patients needing urgent surgery.

Concerns summary Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency information sharing and no identified lead agency for communication.

Concerns summary Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses a significant risk to timely patient care.

Concerns summary Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information was not consistently recorded.

Concerns summary The neonatal unit has insufficient beds and is inadequate for the high number of births, despite an expansion proposal being rejected. This severe lack of facilities poses a high risk to babies' lives.

Concerns summary The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication and information handling within the service.

Concerns summary There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.

Concerns summary A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital for early infection detection, even if not immediately impactful.

Concerns summary The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical staff also appeared ineffective.

Concerns summary The installed stair lift does not stop in a safe position at the top, leaving the step plate suspended over the stairwell. This creates a falling risk for users and may affect other similar installations.