2019

Concerns summary There is no licensed antidote for Edoxaban anticoagulant, increasing risks for head injury patients. Concerns were raised about the lack of national guidance on antidote administration targets and storage, especially for non-tertiary hospitals.

Concerns summary Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable individuals without adequate human rights safeguards.

Concerns summary An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.

Concerns summary A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways end, significantly increasing the risk of serious collisions.

Concerns summary Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.

Concerns summary Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.

Concerns summary A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.

Concerns summary The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.

Concerns summary The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.

Concerns summary Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.

Concerns summary Limited 24/7 hyper acute stroke unit availability in Greater Manchester led to extended ambulance travel and delayed urgent medical assessment, impacting patient care, especially overnight.

Concerns summary The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing to fatal injuries from uncapped poles.

Concerns summary A concern was raised regarding the lack of clinical assessment for frail persons resident at Glebelands following falls.

Concerns summary Delays in critical medical procedures due to a shortage of specialists, coupled with an unreliable postal system for GP communication and poor inter-hospital communication, risked patient safety.

Concerns summary No clear system existed for escalating or prioritizing urgent OGD procedures when capacity was an issue. Additionally, deviations from best practice timescales lacked documented rationale or senior clinician approval.

Concerns summary The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating improved watchtower manning and safety equipment.

Concerns summary Inadequate procedures for communicating and acknowledging medication changes, lack of systems for carers to confirm care plan adherence, and poor record-keeping by the care provider created significant medication error risks.

Concerns summary Concerns were raised about the initial over-prescription of opiates, leading to dangerously high levels and adverse effects. The impact of these high doses was not adequately understood or managed.

Concerns summary Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.

Concerns summary Mental health issues were overlooked due to a focus on alcohol dependency, and the patient was denied care as his condition didn't fit service criteria. Teams lacked awareness of referral criteria and dismissed GP insights, hindering appropriate treatment.

Concerns summary The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.

Concerns summary Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.

Concerns summary Incomplete medical records failed to accurately relay critical patient vulnerabilities to telecare providers. Additionally, responder contact details were not integrated into the call handling system, and there was no automatic flagging for medical risks.

Concerns summary Ambulance control failed to adequately assess the immediate danger of Maureen's admitted actions, leading to a significant delay in response and missed opportunities to enlist other agency support or inquire about her location and potential assistance.

Concerns summary A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing to numerous near misses and non-fatal collisions.