2019

Concerns summary The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.

Concerns summary A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.

Concerns summary Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.

Concerns summary Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.

Concerns summary Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent need for highway safety improvements.

Concerns summary The Early Intervention Team lacks specialist substance abuse workers for dual-diagnosis patients, and significant waiting times for talking therapies are hindered by recruitment and retention issues.

Concerns summary Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.

Concerns summary Police officers widely misunderstood Domestic Abuse policy, failed to use system markers or recognize non-fatal strangulation as a risk factor, conducted inadequate assessments, and critical recommendations remained unimplemented.

Concerns summary There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk to patient safety.

Concerns summary Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm to others.

Concerns summary Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call regrading.

Concerns summary Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols across trust sites created inconsistent care standards.

Concerns summary Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.

Concerns summary Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT reviews.

Concerns summary Unclear road markings and a confusing road layout contributed to motorist confusion, posing a risk of future accidents.

Concerns summary A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.

Concerns summary Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.

Concerns summary Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.

Concerns summary Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.

Concerns summary Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons unit.

Concerns summary Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.

Concerns summary Concerns arose that patient mobility, a key indicator of declining health, was not systematically assessed alongside other wellness scores in hospital care.

Concerns summary Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.

Concerns summary Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family contact and local support.

Concerns summary A fundamentally flawed patient safety investigation into a fall highlighted inadequate investigation training and a lack of guidance for frontline staff on capturing immediate post-fall evidence.