2017

Concerns summary The communal fire alarm system at Honiton Oaks failed to trigger audible alerts within individual flats, raising serious safety concerns for residents, particularly those with mobility problems under a "Stay Put" policy.

Concerns summary Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.

Concerns summary Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check on the deceased's wellbeing.

Concerns summary London's Cycle Super Highways and roads suffer from inadequate systems for determining and monitoring grip levels. Urgent research is needed on scientific grip value assessment and the adverse effects of adjacent areas with differing grip.

Concerns summary The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.

Concerns summary Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a lack of appropriate management to ensure nurses adhered to observation guidelines.

Concerns summary Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.

Concerns summary The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an Enhanced Care/Observation Standard Operating Procedure remain unclear.

Concerns summary Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday parties, and failures to follow safety procedures, including non-functional CCTV.

Concerns summary Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of support upon discharge.

Concerns summary The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.

Concerns summary The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.

Concerns summary The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is critically needed, as current separation of care increases risk.

Concerns summary The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.

Concerns summary Harbour Healthcare failed to implement alarms for insecure internal doors, highlighting a risk assessment "blind spot." The CQC must review regulations and inspection procedures for door safety, and Stockport NHS guidelines lack clarity on CT scan requirements.

Concerns summary High-powered kit cars are sold without requiring specific driving courses, and their post-initial testing lacks rigor. Inexperienced drivers can operate these vehicles with a standard license, unlike the graduated system for motorcycles.

Concerns summary Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her self-inflicted death.

Concerns summary A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in inadequate escalation of patients with bleeds for specialist review.

Concerns summary A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to the death in Roker Harbour.

Concerns summary Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear prohibition policy.

Concerns summary Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.

Concerns summary Care home staff received inadequate training to recognise emergency situations and relied on presumptions when encountering an unresponsive patient.

Concerns summary The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.

Concerns summary An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, despite the known risks.

Concerns summary Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness during subsequent assessments.