2017

Concerns summary The hospital failed to implement identified strategies to address missed opportunities in acting on reducing haemoglobin trends, demonstrating a critical delay in adopting patient safety improvements post-Root Cause Analysis.

Concerns summary Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).

Concerns summary An urgent dental referral was sent by slow postal service, and the subsequent maxillofacial appointment was significantly delayed for nearly seven weeks due to cancellation and rescheduling.

Concerns summary The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.

Concerns summary Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.

Concerns summary The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The hospital also lacked a protocol for vulnerable patients who self-discharge, particularly regarding follow-up and essential medication.

Concerns summary The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.

Concerns summary There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, were seen and re-engaged, leading to discharge without adequate follow-up after an initial appointment failure.

Concerns summary Inconsistent use of high-resolution X-ray screens and clinician confirmation bias led to missed abnormalities. There were also unclear processes for reinforcing learning and escalating patient deterioration to consultants.

Concerns summary There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, with the crisis team unable to fill this gap.

Concerns summary Inadequate warning signage and obstructed visibility at a hazardous crossroads, combined with a failure to implement previously recommended safety improvements due to resource issues, created a significant risk.

Concerns summary Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not being used despite immobility and involuntary movements.

Concerns summary The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. Additionally, communication with the supportive family regarding the patient's elevated risk was insufficient.

Concerns summary Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.

Concerns summary Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.

Concerns summary A resident was unable to effectively use a call-bell due to potential unawareness of its portability or mobility limitations, highlighting a lack of consideration for alternative wearable alarm systems.

Concerns summary Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.

Concerns summary Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's regulations, and current "best practice" recommendations carry no enforcement.

Concerns summary Inadequate highway inspection practices failed to document carriageway deterioration, and a proposed new management procedure risks increasing deaths, particularly for cyclists, by raising the threshold for defect investigation and repair.

Concerns summary The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation significantly increases the risk of serious incidents.

Concerns summary A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.

Concerns summary Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.

Concerns summary Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check on the deceased's wellbeing.

Concerns summary London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research is needed on scientific grip value assessment and the adverse effects of adjacent areas with differing grip.

Concerns summary The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.