2018

Concerns summary A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change prioritizing reduced restrictive practices.

Concerns summary Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, representing missed opportunities to provide supportive measures.

Concerns summary A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still be in use in other hospitals despite safer alternatives existing.

Concerns summary The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with the care team.

Concerns summary An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine fracture.

Concerns summary The analogue Careline system caused significant delays for emergency services due to connection times, a single phone line, and key safe access issues, potentially unknown to residents.

Concerns summary The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals with unrecognised cognitive impairment from driving.

Concerns summary A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not available in the UK, even for compassionate use.

Concerns summary A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.

Concerns summary The worksite lacked a safe system of work, and there was a widespread practice of employees not wearing seatbelts, with inadequate systems to check compliance.

Concerns summary Excessive vehicle speeds, inadequate pedestrian barriers, and confusing cycle lane signage contribute to dangerous road crossing practices by pedestrians and cyclists on Barrack Road.

Concerns summary The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.

Concerns summary Persistent paramedic vacancies continue to cause concerns regarding the timely despatch and arrival of ambulances, posing a risk of future deaths due to delayed emergency response.

Concerns summary Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from unprogressed requests and incorrect referral classifications.

Concerns summary Significant delays in vital drainage and ERCP procedures occurred due to insufficient radiology staff, inadequate escalation, and a lack of cover during a consultant's annual leave, putting patients at risk.

Concerns summary The walk-in centre's triage process was judged adequate by the CQC despite lacking vital clinical observations, unlike secondary care, creating an unacceptable safety risk for unscreened patients.

Concerns summary There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis situations, highlighting a need for better training in emergency management.

Concerns summary Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.

Concerns summary A post-operative patient's condition significantly deteriorated during a prolonged 4-hour patient transport journey home after hospital discharge, raising concerns about monitoring during transit.

Concerns summary Concerns arose regarding unmanaged long-term zopiclone addiction and the immediate cessation of the drug, which was done to prevent serious self-harm.

Concerns summary Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication with the family about an initial fall.

Concerns summary Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert clinicians to new results, hindering diagnosis before discharge.

Concerns summary Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold natural waters, highlighting a systemic risk of drowning without curriculum changes.

Concerns summary Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to informal versus sectioned patients, despite similar risks.