2019

Concerns summary An external maintenance staircase, not requiring regular public access, was easily accessible and unsecured, posing a safety risk.

Concerns summary The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.

Concerns summary Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.

Concerns summary Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.

Concerns summary GPs prescribed Diazepam without verifying consultant advice or checking for illicit access, and the practice had not reviewed its prescribing approach for this medication.

Concerns summary A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.

Concerns summary The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.

Concerns summary A child was discharged after a prolonged seizure without sufficient observation, and neuroprotective strategies for potential hypoxic brain injury were not considered by the hospital.

Concerns summary The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, poor documentation, and a lack of processes for reviewing significant events to learn from them.

Concerns summary Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.

Concerns summary The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would be followed to prevent future deaths.

Concerns summary The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.

Concerns summary The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.

Concerns summary CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

Concerns summary The ambulance service failed to communicate crucial pregnancy information during hospital alerts and handover, causing significant delays in obstetric care and leading to inappropriate medical treatment.

Concerns summary Concerns arose that the deceased, despite expressing suicidal ideation, was incorrectly deemed ineligible for CAMHS intervention and was not assessed by a consultant psychiatrist, nor given clear advice for persistent suicidal feelings.

Concerns summary Lack of early intervention mental health support for young people not meeting CAMHS thresholds, coupled with poor information sharing between health agencies and the removal of medically qualified staff in schools, hindered comprehensive care.

Concerns summary National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts to mitigate this through triage are hampered by insufficient resources.

Concerns summary Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental health beds, and inadequate oversight of private providers contributed to significant care failures. Additionally, universities need better training for staff to recognize mental health issues.

Concerns summary Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.

Concerns summary Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital information being overlooked due to convoluted dissemination methods and outdated guidance.

Concerns summary Lack of national guidance and inconsistent operator practices regarding tow hitch inspection and engagement risk disengagement due to foreign objects not visible on visual inspection.

Concerns summary The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment system for shotgun certificates is flawed, with officers lacking skills to evaluate complex health conditions.

Concerns summary A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate FEO skills, create risks.

Concerns summary Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.