2019

Concerns summary ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.

Concerns summary Inadequate Mental Capacity Act training resulted in staff failing to understand decision-making processes, consultation requirements, and the need to explore all options, leading to unconsulted and potentially inappropriate treatment decisions.

Concerns summary Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for anaemia management and iron infusion observation were not followed, compounded by unrecorded pharmacist-clinician discussions.

Concerns summary Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or adequate safety features. This leads to routine unsafe practices, with riggers having minimal influence over their own fall protection.

Concerns summary Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained health advisors who inadequately considered reported symptoms of a medical emergency.

Concerns summary The Trust repeatedly ignored its own transfer policy, leading to unnecessary patient movements, and failed to implement promised improvements from previous PFD reports concerning transfer protocols.

Concerns summary Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.

Concerns summary A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed diagnoses, and wasted time for complex cases.

Concerns summary Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.

Concerns summary Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of venue protocols, poor communication, and a chaotic scene that delayed CPR and ambulance access.

Concerns summary An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.

Concerns summary Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks sufficient reporting requirements, investigative powers, and sanctions for such discrepancies.

Concerns summary Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical information.

Concerns summary Inconsistent post-16 mental health services, long autism diagnosis waiting lists, and schools' lack of understanding for accelerated autistic adolescents create high-risk situations for mental health and self-harm.

Concerns summary Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.

Concerns summary GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.

Concerns summary GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.

Concerns summary The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.

Concerns summary The 999 call system caused confusion and delays in emergency response for a mental health crisis at home due to unclear agency responsibilities and lack of public awareness.

Concerns summary A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an emergency situation.

Concerns summary NHS 111 and Out of Hours services lack mandatory annual training for staff on paediatric symptoms, sufficient specialist clinical review, and clear guidance to default to ambulance calls for sick children.

Concerns summary The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.

Concerns summary Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack of industry awareness about associated risks.

Concerns summary Ineffective placement of pressure mats allowed residents to bypass them, and unreliable audible alarms meant falls went undetected by staff.

Concerns summary Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment team, highlighting a systemic failure in handover procedures.