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 Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.

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 The provided text outlines the coroner's duty to report matters of concern but does not detail any specific safety issues or systemic failures.

Concerns summary The A34 bypass at Melrose Way Bend is dangerous due to the absence of a continuous white line, allowing unsafe overtaking in dark conditions and posing a risk to lives.

Concerns summary A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself is complex and lacks clear protocols for individual risk and new fitness tests.

Concerns summary The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.

Concerns summary The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.

Concerns summary Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on family input, without direct verification of the correct dosage.

Concerns summary A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental state and specific concerns not being recorded.

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 Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, alongside conflicting assessments of the patient's body temperature.

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 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 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 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 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 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.