2019

Concerns summary Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.

Concerns summary The university fails to effectively utilize mental health disclosures, relying on email invitations for support that many students do not respond to, and withholding vital information from tutors due to data protection.

Concerns summary Medical staff struggled to access vital patient information from electronic notes, highlighting potential issues with the system's effectiveness, staff training, and the methods for recording and retrieving critical data.

Concerns summary Ford's vehicle design should include fault code provision for engine shutdowns caused by the DMF protection system, and the manufacturer has yet to conduct a forensic examination to identify relevant faults.

Concerns summary There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with Acute Behavioural Disturbance, despite its effectiveness for safe treatment and transport.

Concerns summary A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.

Concerns summary Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking clear protocols for urgent upgrades when airways are compromised. There's also no pathway for updating prison staff or facilitating dialogue with hospital EDs on call categorisation.

Concerns summary Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record entries, failing to provide timely, vital information for subsequent shifts.

Concerns summary Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.

Concerns summary Capacity limitations due to a surge in referrals delayed critical surgery, leading to a higher chance of death due to sepsis. Insufficient resources and beds risk future preventable deaths.

Concerns summary Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.

Concerns summary Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge areas and confusing signage on dynamic hard shoulders, increasing the risk of fatal collisions.

Concerns summary Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.

Concerns summary There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, especially for older and frailer individuals.

Concerns summary Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in equipment use and moving/handling.

Concerns summary Risks included unsupervised bathing for residents with seizure risk, GP unawareness of critical issues like hoarding, failed medication compliance systems, and inconsistent reporting/monitoring for absconding incidents.

Concerns summary There are continuing concerns regarding the high volume and speed of traffic on the B5017, particularly at junctions, warranting a further review to improve road safety.

Concerns summary The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.

Concerns summary No specific safety concerns were identifiable from the provided administrative text.

Concerns summary Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.

Concerns summary Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.

Concerns summary West Sussex County Council's drain clearance risk assessment was inadequate, failing to account for specific blockages and lacking regular review or warning signs for known flood risks, despite available data and increased storm severity.

Concerns summary Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear communication of risks or guidance to sentencing courts.

Concerns summary A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a trauma series CT scan or c-spine imaging.

Concerns summary The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of a learning disability liaison role.