2019

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 The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.

Concerns summary The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.

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 There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory guidance for pharmacists on online prescriptions lacks mandatory adherence and clear sanctions.

Concerns summary The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with stationary vehicles, especially given high speeds and limited escape options on elevated stretches.

Concerns summary There is a lack of clear national and local guidance for care home staff on safe sleeping positions for vulnerable adults who lack capacity, increasing the risk of unsafe sleeping.

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 Mixing adult and child patients in urgent care centres creates a significant risk of children quietly deteriorating unnoticed, delaying crucial assessment and appropriate referral.

Concerns summary The current road layout and cycle lanes at a junction create a risk of cyclists being struck by left-turning motor vehicles, especially commercial ones, due to poor visibility and positioning.

Concerns summary There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help patients safely wean off addictive prescription opiates.

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 The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, and its safety implications were not reassessed during the 'smart motorway' conversion.

Concerns summary Lack of signage and relatively easy access points allow pedestrians to inadvertently stray onto the A40 near Gibraltar tunnels, posing a risk of future collisions.

Concerns summary A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.

Concerns summary Spire Bristol lacks formal systems for managing unexpected patient reattendances post-discharge, ensuring comprehensive record-keeping, and immediately informing consultants of these cases.

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 The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.

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.