2018

Concerns summary Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a broken camera, lack of emergency alarms/communication, and lapsed first aid certifications at the gym.

Concerns summary Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed to the third-party call centre.

Concerns summary The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.

Concerns summary A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing to the patient's death, highlighting issues with ambiguous terminology and inadequate checking systems.

Concerns summary Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties managing choking risks alongside self-harm concerns for patients eating in bedrooms were identified.

Concerns summary Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate instructions for community monitoring, and a lack of protocols for inter-hospital care transfers.

Concerns summary Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.

Concerns summary Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.

Concerns summary No structured health screening programme is in place for individuals impacted by the Grenfell Tower incident, risking unaddressed future health issues.

Concerns summary A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.

Concerns summary A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the wrong lane, posing significant road safety risks.

Concerns summary Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.

Concerns summary Inadequate railway anti-trespass measures, including poor trespass mat placement, missing platform gates, and insufficient fencing, create a risk of future deaths from track access.

Concerns summary Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.

Concerns summary Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.

Concerns summary Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.

Concerns summary The absence of a central reservation barrier along a specific stretch of dual carriageway allows pedestrian shortcuts, posing a significant risk to public safety.

Concerns summary Concerns exist regarding the lack of rigorous trust policies for returning items like shoelaces and the dreary, unstimulating physical environment in patient rooms, which contributes to boredom.

Concerns summary Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.

Concerns summary Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.

Concerns summary Inadequate communication, delayed assessment of blood results, and missed opportunities for early antibiotic administration led to a failure in recognising the development of sepsis.

Concerns summary The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.

Concerns summary Care home staff had poor understanding of modified diets and lacked systems for correct food preparation and marking. There was also limited understanding of escalating choking episodes to speech and language therapy.

Concerns summary The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist shortages also contributed to backlogs.

Concerns summary A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.