2018

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 Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.

Concerns summary Concerns exist over Airedale Hospital's discharge procedures for head injury patients lacking discharge papers and Riverview Care Home's referral procedures for patients experiencing post-trauma seizures.

Concerns summary Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks further delayed critical intervention.

Concerns summary Confusion regarding responsibility for ensuring windows meet building standards between building control and builders created a false sense of compliance.

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 junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, increasing road safety risks.

Concerns summary GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.

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 Undetected breech births are common due to lack of routine pre-delivery scans, and staff felt uncomfortable challenging a clinician's decision to administer Syntocinon, highlighting systemic issues in challenging inappropriate care.

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 The Community Mental Health Team inappropriately discharged a patient instead of transferring care, and failed to consult required alcohol advisory services, leading to a gap in mental health support.

Concerns summary Many railway platforms lack barriers to prevent accidental contact with live rails, which pose a significant electrocution risk compared to safer overhead power systems used elsewhere.

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.

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 The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Concerns summary Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.

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 A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar future events.

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.