2019

Concerns summary Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.

Concerns summary The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.

Concerns summary The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety issues.

Concerns summary Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.

Concerns summary Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.

Concerns summary Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.

Concerns summary Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.

Concerns summary The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.

Concerns summary Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.

Concerns summary A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.

Concerns summary Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.

Concerns summary Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their duties.

Concerns summary Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.

Concerns summary A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect understanding of duties.

Concerns summary A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.

Concerns summary Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.

Concerns summary There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.

Concerns summary A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.

Concerns summary No specific matters of concern were detailed in the provided text.

Concerns summary Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards intoxication.

Concerns summary Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.

Concerns summary A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of collisions.

Concerns summary Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health unit staff untrained in IV fluid administration were significant issues.

Concerns summary National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.