2018

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

Concerns summary Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.

Concerns summary Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.

Concerns summary The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on licence and had a procedural failure in referring licence breaches back to the Parole Board.

Concerns summary Inadequate road markings, specifically the absence of double yellow lines, allowed legal parking to obstruct visibility, forcing drivers onto the wrong side of the road and increasing accident risk.

Concerns summary A lack of mandatory, compatible anti-collision systems and the absence of Air Traffic Control at a busy airfield created significant collision risks, exacerbated by human eye limitations in adverse weather.

Concerns summary Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.

Concerns summary Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.

Concerns summary Significant backlogs and high demand within Probation services meant a critical court-ordered treatment program for the deceased was not commenced, despite his anxiety to complete it.

Concerns summary A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.

Concerns summary Unavailable medical records, inadequate equipment (missing bronchoscope part, no tilt trolley), and unutilised standard procedures (cricoid pressure, NG tubes) compromised patient care during anaesthesia.

Concerns summary Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.

Concerns summary The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.

Concerns summary The mental health service's rigid 28-day prescription policy for maintenance medication left a patient vulnerable during extended travel, providing unreliable advice about obtaining drugs illicitly abroad.

Concerns summary An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.

Concerns summary A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.

Concerns summary Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for support were not ensured post-discharge.

Concerns summary Delayed surgical fixation of a traumatically fractured femur, caused by initial and subsequent misdiagnoses, led to post-operative complications and significantly contributed to the patient's death.

Concerns summary An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety during work at height.