2019

Concerns summary A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.

Concerns summary Inadequate communication between the hospital and occupational therapist delayed mobility intervention, leading to a minimal exercise regime and increased risk of patient complications.

Concerns summary There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.

Concerns summary Inadequate patient handover between hospitals led to critical medication information loss. Poor fluid balance chart completion, delayed prophylactic anticoagulation, and mental health unit staff untrained in IV fluid administration were significant issues.

Concerns summary National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.

Concerns summary The property lacked a smoke alarm. Emergency services faced difficulty accessing the property due to parked vehicles, hindering response.

Concerns summary Hospital discharge processes failed to ensure confirmed addiction support. A lack of agreed protocols and collaboration with drug services meant referrals were not effectively monitored for vulnerable patients.

Concerns summary Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British Standard for fixing these components, only for their manufacture, creating a safety gap.

Concerns summary Critical ambulance records were not accessed or read by doctors, and senior medical staff lacked professional curiosity. Poor record-keeping and an inadequate system for junior doctor case review by seniors were identified.

Concerns summary The patient transfer checklist failed to require essential oxygen supply checks and tug tests. This systemic flaw meant oxygen flow failure went unnoticed during transfer, risking patient safety.

Concerns summary Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.

Concerns summary Outdated "two week wait" forms remain on the system, causing confusion due to insufficient priority given to their removal. This hinders efficient clinical administration.

Concerns summary Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient staff understanding of "Nil by Mouth" for complex patients.

Concerns summary Inadequate health and safety guidance failed to address work at height risks, leading to an untrained and unsupervised employee performing dangerous tasks without risk assessments. There was also a lack of first aid provision and management training.

Concerns summary Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis and delayed treatment that would likely have resulted in a different outcome.

Concerns summary Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.

Concerns summary Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.

Concerns summary The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.

Concerns summary The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks to patients.

Concerns summary The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.

Concerns summary Citywatch radio reports of serious disturbances are not being relayed to police in a timely manner, risking delayed emergency response and a lack of clear protocols for licensed security staff.

Concerns summary The ambulance call handling system failed to recognize Excitatory Delirium, conflicting guidance for call handlers caused confusion, and training packages contained potentially misleading information, impacting emergency response.

Concerns summary The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.

Concerns summary There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk for residents, despite one having been replaced post-incident.