2017

Concerns 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 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summary Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.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 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 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 Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.

Concerns summary Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded by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 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 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 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 A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a further assessment of her mental state and self-harm risk was missed.

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

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

Concerns 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 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 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 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 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 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 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 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 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 Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.

Concerns 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.

Concerns summary The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by monthly checks to go unnoticed.