2017

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 A missed opportunity in hospital-family communication meant clinicians were unaware of the patient's ongoing delusions, leading to discharge without formal mental health aftercare or family guidance on relapse signs.

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 Airline staff training in cardiac arrest recognition and CPR was inadequate, while ambulance services failed to meet response targets, exacerbated by only one paramedic on duty at the airport, preventing advanced life support.

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 Care home night staff, lacking medical training, failed to consider a head injury as the cause of a resident's confusion after a fall, indicating a need for improved awareness and assessment training.

Concerns summary Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack of industry standards for managing spoil heaps, increasing the risk of accidents.

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 Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.

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 Emergency responders failed to seek medical assistance for a patient with internal hemorrhage after a fall, misinterpreting her symptoms. A subsequent flawed investigation failed to identify critical inaccuracies in risk assessment completion and staff understanding.

Concerns summary A dangerous, uncontrolled pedestrian crossing on a busy dual carriageway is obscured by a wall, located on a bend, and near a speed limit change, creating significant visibility and safety risks for pedestrians.

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 A second death in similar circumstances at the same location highlights a critical failure to implement adequate warning notices, fencing, or other safety measures to mitigate swimming risks.

Concerns summary Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental health services are also unsafely raising referral thresholds.