2018

Concerns summary Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.

Concerns summary A statutory requirement to provide beds for mentally disordered patients in special urgency cases is being ignored, leading to a lack of identifiable beds for high-need individuals.

Concerns summary Systemic failures included ward staff difficulties escalating welfare concerns and making 111 calls, inadequate NWAS investigation and triage by untrained staff, and police confusion over Section 136 powers at private homes.

Concerns summary Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.

Concerns summary Lack of minimum qualifications for lift engineers, a systemic failure to act on regulatory examination findings, and absent care home and lift company protocols for managing maintenance risks contributed to safety concerns.

Concerns summary The provided text is incomplete and does not detail any specific concerns regarding future deaths related to patient deterioration.

Concerns summary Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented proper escalation of patient care.

Concerns summary Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in medical intervention.

Concerns summary Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and subsequently used by the deceased to end her life after a previous suicide attempt.

Concerns summary Inadequate fire detection and warning systems, including missing smoke alarms and kitchen doors, combined with unacceptable escape routes in older maisonettes, pose a significant fire risk in thousands of properties.

Concerns summary Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack of audits, compromised public safety at the football ground.

Concerns summary Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.

Concerns summary Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols raised concerns for patient safety.

Concerns summary Undermined fire safety measures, absent functioning fire detection, and an inadequate alternative escape route in maisonettes place residents at significant risk of death or injury from fire.

Concerns summary Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, created unsafe care practices.

Concerns summary A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.

Concerns summary A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.

Concerns summary Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and the Home Office's conduct during proceedings were also concerns.

Concerns summary Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.

Concerns summary National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.

Concerns summary Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.

Concerns summary A busy A3054 lacks safe pedestrian crossing points, especially for elderly individuals with mobility issues, forcing them to cross dangerously. This hazardous situation has resulted in multiple accidents and near-misses.

Concerns summary The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.

Concerns summary The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.

Concerns summary Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.