2019

Concerns summary Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to significant safety concerns within the prison.

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 Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.

Concerns summary Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.

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 Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.

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 Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.

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.

Concerns summary Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by an unavailable ICU outreach team and poor fluid chart completion.

Concerns summary Poor inter-hospital communication during patient transfers and difficulties securing specialist gastroenterology beds risk patient safety and timely care.

Concerns summary Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.

Concerns summary Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.

Concerns summary Inadequate 111/EMAS triaging, particularly for sepsis, resulted in delayed response. A shortage of ambulances and a high threshold for escalation in the capacity management plan further compromised patient safety.

Concerns summary An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.