2019

Concerns summary The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.

Concerns summary The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.

Concerns summary The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.

Concerns summary There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.

Concerns summary Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.

Concerns summary Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts and a lack of a region-wide approach mean the problem is merely displaced rather than resolved.

Concerns summary Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. Furthermore, safeguarding matters were not logged when individuals were subject to deportation.

Concerns summary The report identified unspecified matters of concern indicating a risk of future deaths.

Concerns summary Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent cases are inadequate, risking rapid patient deterioration.

Concerns summary A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with inadequate monitoring and challenges to deceit.

Concerns summary Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.

Concerns summary A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to confusion about right of way and reduced visibility.

Concerns summary Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.

Concerns summary An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.

Concerns summary A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment orders and inadequate multi-agency coordination. Housing was also overlooked in discharge planning.

Concerns summary Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.

Concerns summary Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect algorithm use, and communication breakdown causing crucial treatment delays in the emergency department. A dangerous gap exists in the triage system for neurological deficits.

Concerns summary Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.

Concerns summary Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.

Concerns summary Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.

Concerns summary The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.

Concerns summary A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.

Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Concerns summary The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.