2017

Concerns summary Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.

Concerns summary A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.

Concerns summary The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.

Concerns summary Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.

Concerns summary Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.

Concerns summary Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.

Concerns summary A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.

Concerns summary A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.

Concerns summary Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.

Concerns summary Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical diagnostic investigations.

Concerns summary Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for call handlers.

Concerns summary The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.

Concerns summary Inadequate communication between hospitals, delayed transfer for critical dialysis, and a lack of a clear plan for patient deterioration led to missed opportunities for timely life-saving treatment.

Concerns On 23"' June 2016 an Investigation was commenced into the death of Dianne Jane MACRAE. The investigation concluded by way of inquest on 17"^ and IS'" May 2017. The medical cause of death was:- 1a)...

Concerns summary A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.

Concerns summary Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.

Concerns summary The absence of warning signs on a road stretch with a high incidence of accidents due to slippery conditions poses an ongoing risk to drivers.

Concerns summary A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.

Concerns summary There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.

Concerns summary The Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.

Concerns summary A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.

Concerns summary A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.

Concerns summary Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Concerns summary A lack of documentation for carer visits and no system for recovering care notes meant care provision issues could not be established. The GP also did not receive a hospital discharge summary.

Concerns summary Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.