2019

Concerns summary Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.

Concerns summary Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.

Concerns summary The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.

Concerns summary The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor inter-agency communication and a severe lack of specialist acute learning disability beds.

Concerns summary Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.

Concerns summary Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.

Concerns summary The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.

Concerns summary There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Concerns summary A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.

Concerns summary Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.

Concerns summary The care home failed to promptly inform medical professionals about falls, adequately handover patient history, or escalate concerns about a patient's deteriorating condition.

Concerns summary Local authority backlogs and staff shortages led to a lack of DoLS and care reviews. Hospital care lacked best interests meetings, IMCA involvement, and caused distress with unbeneficial procedures, including End of Life Care decisions without proper assessment.

Concerns summary The filter lane and junction design fails to prevent drivers from incorrectly turning onto the wrong side of bollards, posing a road safety risk.

Concerns summary Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.

Concerns summary The deceased had a toxic combination of prescribed medications, raising concerns about the monitoring and management of multiple high-dose prescriptions.

Concerns summary Care home forms failed to capture pressure ulcer deterioration or require detailed monitoring, delaying escalation to specialists. There was no system to follow up on unresponsive referrals.

Concerns summary Failure to refer a patient for a clinical geneticist's opinion, despite repeated parental requests and available services, led to a critical underlying condition remaining undiagnosed, resulting in premature death.

Concerns summary A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.

Concerns summary The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.

Concerns summary There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.

Concerns summary A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.

Concerns summary There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant risk of collapse or death during military exercise.

Concerns summary Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.

Concerns summary Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.

Concerns summary A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit and no street lighting, creates a critical hazard where vehicle stopping distances exceed driver visibility.