2017

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 A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of custody protocols for controlled drugs pose risks.

Concerns summary Lack of a consistent, agreed policy between the local authority and care agency regarding actions when service users do not respond or cannot be found.

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 The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for patients.

Concerns summary Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.

Concerns summary Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.

Concerns summary Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future incidents.

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 Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.

Concerns summary The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.

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

Concerns summary Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.

Concerns summary The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an uninvolved nurse practitioner, insufficient safety netting, and failure to commence heparin despite a DVT/PE differential posed significant risks.

Concerns summary Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.

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 Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for national guidelines to ensure consistent, timely treatment.

Concerns summary Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.

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.