2019

Concerns summary A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.

Concerns summary Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.

Concerns summary Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked patient safety.

Concerns summary No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.

Concerns summary The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.

Concerns summary Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on unresponsive referrals.

Concerns summary The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating improved watchtower manning and safety equipment.

Concerns summary Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.

Concerns summary A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.

Concerns summary Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, and poor record-keeping by the care provider created significant medication error risks.

Concerns summary Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not adequately understood or managed.

Concerns summary Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.

Concerns summary Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.

Concerns summary The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.

Concerns summary The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.

Concerns summary There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.

Concerns summary Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.

Concerns summary Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were not integrated into the call handling system, and there was no automatic flagging for medical risks.

Concerns summary A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.

Concerns summary There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant risk of collapse or death during military exercise.

Concerns summary Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist other agency support or inquire about her location and potential assistance.

Concerns summary Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.

Concerns summary Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.

Concerns summary The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction amounts and frequency, poses a significant risk.

Concerns summary A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing to numerous near misses and non-fatal collisions.