2018

Concerns summary Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.

Concerns summary There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.

Concerns summary Ambulance services and patient transport face significant performance gaps due to insufficient funding, leading to critical delays in emergency, high dependency, and non-emergency transfers, risking avoidable deaths.

Concerns summary Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a design flaw allowing guns to fire without a vital safety assembly.

Concerns summary Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them to miss a red light prohibiting them from crossing the main road.

Concerns summary Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.

Concerns summary The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning of danger.

Concerns summary A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.

Concerns summary Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.

Concerns summary An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between contractors for safe isolation.

Concerns summary Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed escalation.

Concerns summary A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.

Concerns summary Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.

Concerns summary A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying a pneumonia diagnosis.

Concerns summary The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.

Concerns summary High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.

Concerns summary The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.

Concerns summary Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.

Concerns summary Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.

Concerns summary Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers failing to appreciate worsening conditions.

Concerns summary Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police in welfare checks were identified.

Concerns summary Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.

Concerns summary It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.

Concerns summary Site security was inadequate, with an accessible turnstile allowing unauthorised entry, and a lack of contingency plans or improved equipment for security officers.