2019

Concerns summary Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, placing patients' lives at ongoing risk.

Concerns summary Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.

Concerns summary Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.

Concerns summary Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.

Concerns summary An elderly patient with advanced dementia received incomprehensible discharge information and inadequate follow-up due to ED overcrowding, suboptimal imaging, delayed senior review, and failed contact attempts.

Concerns summary The nightclub's protocol for calling an ambulance, requiring duty manager approval and a second set of observations, created dangerous delays in emergency response.

Concerns summary A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.

Concerns summary Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when cardiac arrest officially begins.

Concerns summary Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.

Concerns summary A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.

Concerns summary Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.

Concerns summary Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.