2018

Concerns summary Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.

Concerns summary On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received insufficient self-harm training.

Concerns summary A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant risk.

Concerns summary Healthcare providers lacked access to GP records, A&E was understaffed, essential medication administration was delayed, and red flag signs of sepsis were missed due to inadequate examination and protocol adherence.

Concerns summary There is a concern that not mandating 'black boxes' in young drivers' vehicles, which monitor driving actions, misses a significant opportunity to save lives.

Concerns summary The provided concerns text was insufficient to identify specific safety issues or systemic failures.

Concerns summary Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients at risk of falls.

Concerns summary Inaccurate recording of symptoms by the ambulance service led to an incorrect priority decision and delayed attendance, breaching internal call-back guidelines.

Concerns summary Insufficient pedestrian safety measures on the A63 dual carriageway near Waterloo Manor Hospital pose a significant risk to those crossing.

Concerns summary Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of machines for PEEP therapy, compromised respiratory support.

Concerns summary The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.

Concerns summary A critical gap exists in providing medication to suppress lactation for breastfeeding mothers after infant loss, intensifying psychological distress due to continued milk production.

Concerns summary Electronic mental health records were unclear, making vital history hard to access, and there was a critical lack of communication between mental health teams and GPs.

Concerns summary The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.

Concerns summary Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.

Concerns summary Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.

Concerns summary Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a lack of clear medical cause of death.

Concerns summary A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.

Concerns summary Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed patient care.

Concerns summary Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.

Concerns summary Hospital observation protocols for high-risk patients were not followed, and observation logs were retrospectively falsified, compromising patient safety and preventing timely intervention.

Concerns summary A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from leaving the road where the ground dropped steeply.

Concerns summary Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger event.

Concerns summary Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.

Concerns summary Critical information about recent falls was omitted from discharge paperwork and not communicated during hospital transfer, potentially leading to an unsafe transfer and a subsequent serious fall.