2017

Concerns summary Transport for London displayed an inordinate delay in implementing pedestrian crossings at a dangerous junction, using flawed decision-making based on incomplete accident statistics that omitted overall incidents and near misses.

Concerns summary The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management and potential hospitalisation.

Concerns summary A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.

Concerns summary There was a lack of patient evaluation and incomplete assessment sheets after the deceased's return to the care home, compounded by poor quality hospital documentation lacking detail on clinical decision-making.

Concerns summary Inadequate fencing adjacent to the railway track, specifically behind a scrap metal dealer, presented a significant risk of trespass onto a high-speed line for both adults and children.

Concerns summary Multiple issues included a lack of continuity in medical care, significant gaps in basic nursing observations, failure to recognise patient deterioration, and concerns over 'Hospital at Night' co-ordinators' qualifications for medical prioritisation.

Concerns summary A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.

Concerns summary Critical failures in discharge planning included not identifying a responsible Home Treatment Team or liaising with them. The hospital also failed to contact family/friends despite consent, and the community team did not proactively seek discharge information.

Concerns summary The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.

Concerns summary Volvo vehicle manuals provide insufficient guidance on using automatic i-shift gears for long downhill descents, which could exacerbate brake fade. Manufacturers need to supply clear instructions for these technologies.

Concerns summary The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.

Concerns summary There was a critical failure to assign a single person overall responsibility for the patient, with no new Care Co-Ordinator appointed. A recommendation for all patients to have a lead professional was marked complete but not implemented.

Concerns summary Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.

Concerns summary The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood or implemented by staff. This indicates a systemic failure in falls safety.

Concerns summary Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.

Concerns summary County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.

Concerns summary There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.

Concerns summary Incomplete VTE risk assessments by junior doctors, a consultant's failure to identify this and document their own assessment, and a significant delay in providing thromboprophylaxis.

Concerns summary The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.

Concerns summary Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

Concerns summary Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.

Concerns summary Confusing road layouts with absent pedestrian direction markings, independent green man phasing, and overly visible signals created hazards for pedestrians, especially foreign visitors.

Concerns summary Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet audit targets.

Concerns summary Unclear signage at a motorway junction caused driver confusion about lane usage, and the absence of a run-off lane contributed to queuing traffic.

Concerns summary Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health assessment couldn't be arranged.