2018

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 Pret-a-Manger had inadequate allergen labelling and no robust system to monitor allergic reactions. Additionally, Epipen's needle length and adrenaline dose were identified as dangerously insufficient for adult anaphylaxis.

Concerns summary Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk assessments.

Concerns summary Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.

Concerns summary Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, overstretching Home Treatment Teams.

Concerns summary Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient unsupported due to underfunding.

Concerns summary A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, due to critical bed shortages and underfunding.

Concerns summary Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without training.

Concerns summary Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.

Concerns summary A driver's unsafe practice of only looking straight ahead with minimal eye contact at junctions, to deter other drivers, indicates a systemic failure in safe driving training.

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 Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.

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 Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public on emergency vehicle priority.

Concerns summary A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly deteriorating patient, despite urgent clinical priority.

Concerns summary The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped with such apparatus to improve survival rates in cardiac arrest.

Concerns summary Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.

Concerns summary Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.

Concerns summary The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.

Concerns summary Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping for off-label medication consent, and unread clinical notes, compounded by a lack of statutory consent process for informal patients.

Concerns summary Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.

Concerns summary A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in inadequate facilities, with the care home struggling to meet the patient's requirements.

Concerns summary Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a lack of national guidelines for this procedure.

Concerns summary A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and potentially delayed emergency treatment.

Concerns summary The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history and planning clinical treatment during pregnancy, risking premature births.