2017

Concerns summary (AI summary) The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the absence of a system for sharing information between the Community District Nursing Team and other agencies, and a lack of a system for communicating concerns with the care provider agency.

Concerns summary (AI summary) Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.

Concerns summary (AI summary) A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from accepting crucial preventative treatments.

Concerns summary (AI summary) Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.

Concerns summary (AI summary) The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where impact is absorbed by the crumple zone away from sensors, resulting in severe injury or death.

Concerns summary (AI summary) Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.

Concerns summary (AI summary) The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this hazard and the need for formal risk assessments across sectors.

Concerns summary (AI summary) The deceased's death from meningitis B could have been prevented by vaccination, highlighting an ongoing risk if the teenage group, which is at increased risk, is not included in the vaccination program.

Concerns summary (AI summary) Critical communication breakdown led to both the patient and her GP being unaware of a diagnosed thoracic aneurysm, which was also not placed under surveillance, unlike her abdominal aneurysm.

Concerns summary (AI summary) The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.

Concerns summary (AI summary) Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.

Concerns summary (AI summary) Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded by inconsistent practice and lack of specific ITU guidance.

Concerns summary (AI summary) The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental Health Liaison Service which may have triggered a further assessment.

Concerns summary (AI summary) Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.

Concerns summary (AI summary) Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements and missed public protection opportunities.

Concerns summary (AI summary) Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.

Concerns summary (AI summary) The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.

Concerns summary (AI summary) The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.

Concerns summary (AI summary) Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.

Concerns summary (AI summary) The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.

Concerns summary (AI summary) The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after death.

Concerns summary (AI summary) Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource availability issues, despite the recognised risk of serious complications from prolonged waiting.

Concerns summary (AI summary) Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.

Concerns summary (AI summary) Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. Staff also lacked adequate training.

Concerns summary (AI summary) There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.