2019

Concerns summary Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.

Concerns summary The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.

Concerns summary Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.

Concerns summary Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.

Concerns summary A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.

Concerns summary The junction has a persistently high injury collision rate, requiring urgent improvements to signage, traffic lights, and line of sight, with existing work progressing too slowly.

Concerns summary The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.

Concerns summary Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.

Concerns summary The absence of double solid white lines at a collision site, despite expert opinion they could prevent dangerous manoeuvres, raises concerns about road safety markings.

Concerns summary There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.

Concerns summary Patient care records were not reviewed before assessment, meaning full history and risks were not considered, a recurring issue despite existing staff expectations.

Concerns summary Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.

Concerns summary An unmarked bus stop on a 50mph road without pedestrian facilities created a hazard for alighting passengers, exacerbated by overgrown vegetation and unclear management responsibility.

Concerns summary Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.

Concerns summary The death could have been prevented by daily mental health team visits, formal mental health act assessment, next of kin involvement, and practice nurse input.

Concerns summary The council's reactive bus shelter maintenance system, relying only on public complaints, lacks a proactive inspection regime, leading to delays in identifying and repairing safety issues.

Concerns summary Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.

Concerns summary The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.

Concerns summary Many two-stage pedestrian crossings nationally may lack louvres to prevent 'see-through' confusion from green signals and proper road markings to warn pedestrians of traffic direction.

Concerns summary Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their duties.

Concerns summary A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect understanding of duties.

Concerns summary A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.

Concerns summary A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.

Concerns summary Ineffective trust-wide handovers and a failure to challenge assumptions led to critical delays in diagnosing a head injury due to bias towards intoxication.

Concerns summary A busy crossroads junction lacks pedestrian guard railings, has impaired visibility, and features staggered crossings often misused by pedestrians, contributing to a high rate of collisions.