2018

Concerns summary The current AAA screening program excludes individuals over 65 at its introduction, and the "opt-in" nature for asymptomatic conditions may hinder participation, risking undetected aneurysms.

Concerns summary Elderly patients on blood thinners are at risk due to delayed CT scans after falls, as deterioration signs can be delayed. Communication failures, including language barriers and inadequate information sharing with family, further compromise care.

Concerns summary Inconsistent risk assessment and classification of a patient, combined with a delayed police notification policy for absconding low-risk patients, led to an unacceptable delay in emergency response.

Concerns summary Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable to challenge decisions, impacting patient safety.

Concerns summary Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.

Concerns summary Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic treatment facilities. This systemic failure, highlighted repeatedly over a decade, risks future deaths.

Concerns summary Inadequate information sharing and unstructured communication between EMAS and hospital staff, combined with paramedics lacking experience and support for complex obstetric emergencies, compromised patient care.

Concerns summary Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.

Concerns summary Waivers for recreational water activities fail to disclose risks for participants with epilepsy or gather essential past medical history, compromising safety for vulnerable individuals.

Concerns summary The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was unaware of this critical pathway.

Concerns summary Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.

Concerns summary British consulate/embassy communication channels were inadequate and unresponsive to family attempts to assist with medical treatment for an ill British national abroad, potentially impacting care outcomes.

Concerns summary No specific concerns for future deaths were detailed in the provided text.

Concerns summary There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to national guidelines on this crucial patient information.

Concerns summary Security guards failed to respond to an activated fire exit alarm at a location with a history of a near-fall incident, indicating inadequate safety protocols and response.

Concerns summary Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.

Concerns summary A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and a problematic solid white line create significant safety risks.

Concerns summary A non-medically qualified counsellor charged an inpatient for non-treatment visits and failed to advise them on financial alternatives, revealing a systemic omission in Addcounsel's practices.

Concerns summary There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders passing through dangerous aftermaths.

Concerns summary Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.

Concerns summary British Cycling does not conduct health assessments or medical screening for young riders on its World Class Programme, missing opportunities to identify potential cardiac abnormalities.

Concerns summary The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its possession or supply illegal.

Concerns summary Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.

Concerns summary Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.

Concerns summary W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with inconsistent records.