2017

Concerns summary (AI 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 (AI summary) Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.

Concerns summary (AI 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.

Concerns summary (AI summary) There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.

Concerns summary (AI summary) Inadequate patient supervision, staff unawareness of visitor departures, and overcrowded wards with pressured junior staff accepting high-needs patients created an unsafe care environment.

Concerns summary (AI summary) Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of existing users.

Concerns summary (AI summary) Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.

Concerns summary (AI summary) Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.

Concerns summary (AI summary) A high falls risk patient was denied a sensor mat based on mental capacity, demonstrating a policy requiring urgent review for potentially neglecting safety needs.

Concerns summary (AI summary) The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.

Concerns summary (AI summary) Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and lack of Trust-wide learning from errors.

Concerns summary (AI summary) Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.

Concerns summary (AI summary) There were failures to actively cross-check for shockable rhythms and to routinely use defibrillators in AED mode during cardiac arrest incidents, highlighting a need for improved staff training.

Concerns summary (AI summary) The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response to a request for urgent assessment; the coroner remains concerned that these failings could recur.

Concerns summary (AI summary) An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.

Concerns summary (AI summary) Inadequate fall prevention measures included insufficient observations, failure to identify fall patterns, and a lack of recorded meaningful activities. Unsuitable non-slip footwear also posed a risk.

Concerns summary (AI summary) Concerns include inadequate training on patient scoring systems, a failure to provide doctors with nurses' medical notes, and doctors' failure to correctly diagnose pulmonary embolism.

Concerns summary (AI summary) The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.

Concerns summary (AI summary) The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing and effective care escalation.

Concerns summary (AI summary) Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.

Concerns summary (AI summary) General practitioners lacked direct urgent access to CT scanning, unlike those in neighboring areas. This commissioning issue risks delaying diagnoses and potentially impacting patient outcomes.

Concerns summary (AI summary) A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.

Concerns summary (AI summary) Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.

Concerns summary (AI summary) Junior medical staff lacked awareness of liver failure's impact and early hypovolaemia, delaying critical treatment and consultant input. Inadequate nursing procedures and ineffective mortality reviews further compromised patient safety.

Concerns summary (AI summary) Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.