2019

Concerns summary Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for appropriate care.

Concerns summary Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses an ongoing risk, despite awareness of the need for improvements.

Concerns summary Clinicians may lack awareness of the fatal risks of epistaxis, particularly in vulnerable patients on oxygen or Warfarin, and failed to recognize its significance in clinical records.

Concerns summary A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means many are unaware of risks from older blinds, leading to child strangulation deaths.

Concerns summary Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's continued operation with inadequate care and record-keeping poses a significant risk of future deaths.

Concerns summary A significant gap in mandatory basic life support training for prison officers employed during a specific period leads to delayed CPR, with no retrospective training efforts to rectify this.

Concerns summary A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a child with complex needs. Inconsistent understanding of protocols and the "red book" exacerbated these issues.

Concerns summary A mental health trust failed to follow up and share information with the Probation Service regarding a patient associating with a high-risk individual. This breakdown in inter-agency communication prevented consideration of further safeguards.

Concerns summary The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.

Concerns summary Employees are repeatedly exposed to polycyclic aromatic hydrocarbons without protective equipment, despite a clear link to cancer, posing a significant ongoing health risk.

Concerns summary Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.

Concerns summary There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Concerns summary Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a fatal overdose.

Concerns summary Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.

Concerns summary Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, potentially missing cases requiring immediate hospital transfer.

Concerns summary A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.

Concerns summary The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.

Concerns summary Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.

Concerns summary A paramedic was inappropriately instructed to perform an untrained hernia reduction, causing pain, when the patient should have been transferred to hospital for a suspected strangulated hernia, possibly due to pressure to avoid admissions.

Concerns summary Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.

Concerns summary A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.

Concerns summary There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.

Concerns summary Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.