2019

Concerns summary Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.

Concerns summary Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.

Concerns summary There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.

Concerns summary Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable individuals without adequate human rights safeguards.

Concerns summary The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.

Concerns summary An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.

Concerns summary The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor inter-agency communication and a severe lack of specialist acute learning disability beds.

Concerns summary A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways end, significantly increasing the risk of serious collisions.

Concerns summary Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.

Concerns summary Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.

Concerns summary Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.

Concerns summary Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.

Concerns summary The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.

Concerns summary There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Concerns summary A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.

Concerns summary A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.

Concerns summary The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.

Concerns summary The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.

Concerns summary Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.

Concerns summary The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns about a patient's deteriorating condition.

Concerns summary Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused distress with unbeneficial procedures, including End of Life Care decisions without proper assessment.

Concerns summary Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.

Concerns summary Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.

Concerns summary The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing to fatal injuries from uncapped poles.

Concerns summary The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of bollards, posing a road safety risk.