2019

Concerns summary Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.

Concerns summary The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.

Concerns summary Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.

Concerns summary Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.

Concerns summary Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information that callers remote from the patient cannot provide, risk inadequate and delayed emergency response.

Concerns summary Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.

Concerns summary Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.

Concerns summary Safety on a road known for speeding and overtaking would be improved by extending double white lines to restrict dangerous overtaking maneuvers.

Concerns summary Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged debris.

Concerns summary Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex cases.

Concerns summary There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with staff lacking understanding of police protocols and information requirements, leading to delayed high-risk classification.

Concerns summary The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.

Concerns summary Wokingham Station has insufficient and poorly located signage for the live third rail, with no warnings visible from main platform areas or tactile paving, despite high footfall and significant electrocution risk.

Concerns summary Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.

Concerns summary Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.

Concerns summary A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs from accessing a complete list of previous prescriptions.

Concerns summary Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to unsuitable placements and a lack of post-admission care plans and risk assessments.

Concerns summary Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.

Concerns summary The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or equipment for water rescue, alongside unclear emergency procedures.

Concerns summary Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.

Concerns summary Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.

Concerns summary A consultant lacked understanding of appropriate patient transfers and capacity assessments, while key staff were unaware of internal investigation findings. An essential transfer protocol also remained uncompleted, risking inappropriate discharges.

Concerns summary Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, despite previous assurances.

Concerns summary A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.