2017

Concerns summary A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.

Concerns summary Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.

Concerns summary The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood or implemented by staff. This indicates a systemic failure in falls safety.

Concerns summary Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.

Concerns summary County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.

Concerns summary There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.

Concerns summary Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay in providing thromboprophylaxis.

Concerns summary The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.

Concerns summary An unprotected level crossing lacked warning systems, causing confusion when multiple trains passed, and double-height freight carriages obscured views, increasing pedestrian danger.

Concerns summary Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

Concerns summary There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.

Concerns summary An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.

Concerns summary Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect patient scores and policy non-adherence.

Concerns summary Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.

Concerns summary A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.

Concerns summary Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards for pedestrians, especially foreign visitors.

Concerns summary Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet audit targets.

Concerns summary Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication protocols between staff and ambulance services were inconsistent.

Concerns summary Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off lane contributed to queuing traffic.

Concerns summary Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health assessment couldn't be arranged.

Concerns summary A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the encounter.

Concerns summary Lack of clear written procedures for lone staff dealing with trespassers, inconsistent practice, and difficult access to CCTV for verification contributed to confusion and unconfirmed assumptions.

Concerns summary Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear roles, poor observation recording, and deficient handover systems.

Concerns summary The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting a need for better training.

Concerns summary Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued this essential training.