2017

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 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.

Concerns summary A high-risk falls resident sustained injuries due to an unplugged falls mat, unrecorded observations, and inadequate handover information for agency staff regarding critical safety measures.

Concerns summary Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.

Concerns summary GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.

Concerns summary Multiple deaths occurred on a ward due to inadequate, incomplete, and unenforced falls risk assessments. Policies for vulnerable patients and the monitoring of falls prevention procedures were insufficient.

Concerns summary Multiple deaths resulted from inadequate, incomplete, or unenforced falls risk assessments on the ward, including poor documentation, lack of intervention, and failure to address risks at handover.

Concerns summary The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.

Concerns summary Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm prevention.

Concerns summary Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due to an apparent lack of awareness regarding their complex needs.

Concerns summary Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.

Concerns summary A lifeguard failed to notice a submerged swimmer for over five minutes due to inadequate pool safety protocols, including insufficient staffing and static positioning. The coroner suggests using the CCTV footage as a national training tool to improve vigilance.

Concerns summary Carers' concerns were not escalated or recorded, and staff failed to appreciate the importance of incident reports for illness. Delays in calling emergency services occurred due to staff channelling medical issues through managers, who then underestimated the situation's seriousness.

Concerns summary Nursing home staff were inadequately equipped to manage a patient with complex mental and physical ill health, particularly regarding self-harm risks. Incomplete record-keeping, potentially due to high workload, and underutilised computer systems also raised concerns.

Concerns summary The care home failed to notify the family and corporate risk of a resident's injury, preventing proper investigation and learning. Incident reporting relied on a single, departed manager, with no audit or review since, despite missing documentation.

Concerns summary A young person with suicidal ideation faced critical delays in receiving an urgent mental health review, despite family concerns. The practitioner lacked protocol awareness and conducted subjective risk assessments, further compounded by transitioning services and possible masking of symptoms.

Concerns summary Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.

Concerns summary The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph speed limit on this challenging single carriageway road.

Concerns summary Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes placement in adult crisis units and unsupervised supported living post-assessment.

Concerns summary A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.

Concerns summary The level crossing lacked CCTV monitoring and was prone to misuse due to insufficient half-barriers. The coroner suggested full-length barriers to prevent future incidents.

Concerns summary There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.

Concerns summary The fire drills policy lacked safeguards to adequately monitor residents, especially those with dementia, before, during, and after drills.

Concerns summary Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.