2017

Concerns summary There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.

Concerns summary Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.

Concerns summary Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.

Concerns summary Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.

Concerns summary Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.

Concerns summary Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.

Concerns summary Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely senior clinician contact were identified concerns.

Concerns summary Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.

Concerns summary Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and inadequate consideration of previous medical records before discharge.

Concerns summary Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.

Concerns summary A serious patient injury lacked a formal investigation, limiting learning opportunities to improve resident safety, despite policy improvements.

Concerns summary Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.

Concerns summary The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This created a significant risk of missed appointments and inadequate care review.

Concerns summary There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system to track works orders or audit completion and quality, leading to the wrong repair being performed.

Concerns summary The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The family also faced barriers in sharing critical information with professionals.

Concerns summary Jaundice in children beyond the neonatal period is under-recognised by doctors. Non-escalation to specialists can adversely affect care and be life-threatening, especially when organ transplantation may be critically needed.

Concerns summary The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.

Concerns summary Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.

Concerns summary The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap in the vehicle restraint barrier, which allows unimpeded traffic access.

Concerns summary The absence of "no through road" signs at the start and reflective warnings at the dead-end wall risks drivers reaching a sudden, unexpected obstruction.

Concerns summary Emergency service triage software failed to register a head injury in an anticoagulant patient after a fall, risking severe complications and highlighting the need for a review of head injury recognition protocols.

Concerns summary An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.

Concerns summary The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being too small on packaging and absent from the device itself.