2019

Concerns summary Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline first aiders, significantly reducing actual direct medical provision.

Concerns summary School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.

Concerns summary Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.

Concerns summary A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.

Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Concerns summary Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.

Concerns summary The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.

Concerns summary Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.

Concerns summary Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.

Concerns summary There was an inadequate discharge and pre-assessment process between care homes concerning the requirement for subcutaneous fluids.

Concerns summary Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.

Concerns summary A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.

Concerns summary The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing work progressing too slowly.

Concerns summary A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.

Concerns summary There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.

Concerns summary The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.

Concerns summary Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.

Concerns summary The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous manoeuvres, raises concerns about road safety markings.

Concerns summary There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.

Concerns summary Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring issue despite existing staff expectations.

Concerns summary Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick removal over adequately assessing the reasons for a detainee's distress or resistance.

Concerns summary Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and unclear management responsibility.