2018

Concerns summary A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.

Concerns summary Safety-netting advice provided upon discharge focused solely on headaches, failing to include information about the differential diagnosis of meningitis, despite it being considered.

Concerns summary Emergency Department demand prevented meeting triage targets, early paediatrician involvement for very young children was not ensured, and on-call consultants were not called despite significant demand.

Concerns summary A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.

Concerns summary Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.

Concerns summary Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.

Concerns summary The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring high-sided vehicles to use the center, exacerbated by a lack of priority signage.

Concerns summary Risk assessments for path closures are inadequate for unique routes without alternative access, leading pedestrians to disregard barriers and use hazardous excavations.

Concerns summary Critically underfunded child and adolescent mental health services in Cumbria result in long treatment delays, risking lives and causing lasting harm.

Concerns summary Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.

Concerns summary Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.

Concerns summary A lack of clear, specific instructions for GP practices on how to refer to the Urgent Care and Assessment team was identified.

Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.

Concerns summary Inconsistent mental health service commissioning in Greater Manchester means Trafford residents lack out-of-hours emergency GP referrals, forcing A&E attendance or police involvement.

Concerns summary No specific concerns were detailed in the provided text, only a reference to appended concerns.

Concerns summary The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.

Concerns summary Compromised visibility at a crossroads junction, despite existing signage, necessitates urgent improvements like renewed signs, rumble strips, and "Stop" signs, but these lack an implementation timeframe.

Concerns summary Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.

Concerns summary Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing essential contact.

Concerns summary Extremely poor lighting and lack of CCTV near the canal made it difficult to discern the water from the land at night, posing a significant safety risk.

Concerns summary Staff provided unsuitable food to a high-risk choking patient on a soft diet and left her unsupervised during meals, contrary to safety assessments.

Concerns summary Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, and significant CT scan delays.

Concerns summary Inadequate staff training for a new IT system resulted in premature closure of patient access plans and lack of reviews, placing multiple patients at risk.

Concerns summary The patient's transfer to his new GP was identified as likely unsafe.

Concerns summary Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.