2017

Concerns summary The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post or follow-up visits, despite known increasing fire risk with product age.

Concerns summary A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of the condition, leading to an underestimation of its felling urgency.

Concerns summary A regional trauma centre lacked a 24-hour consultant plastics surgical service, risking patient lives due to potential delays in urgent debridement for severe infections like necrotising fasciitis.

Concerns summary Ineffective referral and incident reporting systems, poor communication with families, and significant delays in providing first aid after patient falls highlight systemic failures in care and oversight.

Concerns summary Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, hindering investigation.

Concerns summary Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.

Concerns summary Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.

Concerns summary Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.

Concerns summary The highway design lacked stopping restrictions at a dangerous location, despite a nearby safe parking area, creating an unacceptable risk for drivers encountering stationary vehicles at speed.

Concerns summary A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.

Concerns summary The inappropriate termination of an emergency call, due to uncirculated guidance and lack of training, led to a missed opportunity to escalate the need for medical assistance.

Concerns summary Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.

Concerns summary The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.

Concerns summary A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.

Concerns summary Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.

Concerns summary The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.

Concerns summary A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.

Concerns summary There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.

Concerns summary A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.

Concerns summary Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to precarious patient care and significant delays in treatment.

Concerns summary There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.

Concerns summary There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent and prominent safety warnings.

Concerns summary No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.