2019

Concerns summary The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.

Concerns summary The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.

Concerns summary There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working at height on vehicles or trailers.

Concerns summary A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to a fatal collision and highlighting unresolved road safety issues.

Concerns summary The Trust experiences persistent delays in timely referrals for community nursing post-discharge and relies significantly on agency nurses, impacting continuity of patient care.

Concerns summary A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.

Concerns summary Mental health assessments must account for the diurnal nature of reactive depressive illness, as an assessment at a good mood time may invalidate findings when mood is low.

Concerns summary Aircraft operating in unregulated Class G airspace lack electronic proximity warning or collision avoidance devices, relying on the 'See and Avoid' procedure, which poses a safety risk.

Concerns summary Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.

Concerns summary Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.

Concerns summary NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.

Concerns summary Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.

Concerns summary Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.

Concerns summary The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses a risk of future deaths.

Concerns summary A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer guidance on cardiac monitoring.

Concerns summary Inadequate guidance for caring for non-verbally communicative patients, poor record-keeping with missing entries and incomplete records, and significant miscommunication among medical and nursing staff compromised patient care.

Concerns summary Critical patient information regarding a potential blood clot was not recorded or passed on, and a requested D-Dimer test result was not seen by the discharging doctor due to systemic record-keeping failures and inadequate alert systems.

Concerns summary An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for reliability.

Concerns summary A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of system to alert odd behaviour or alarms at platform end barriers.

Concerns summary Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, contributed to a patient's death by suicide following a mental health relapse.

Concerns summary The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.

Concerns summary There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.

Concerns summary School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.

Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.