2020

Concerns summary There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.

Concerns summary Inadequate barrier construction and fencing on a railway platform allowed a pedestrian to access the track, despite warnings, with previous similar incidents noted.

Concerns summary Road safety concerns at a blind bend include poor visibility for right turns from a driveway, inappropriate speed limits, and the absence of warning signs.

Concerns summary A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.

Concerns summary Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate this as a serious incident.

Concerns summary Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone handling them.

Concerns summary Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.

Concerns summary Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.

Concerns summary Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.

Concerns summary Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.

Concerns summary GP failed to recognise dehydration risk and document observations. Paramedics' national triage tool did not clearly mandate immediate transfer for sepsis. Care home staff lacked national guidance on recognising and escalating dehydration risks.

Concerns summary A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.

Concerns summary NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. The call was then closed due to an incorrect number, missing a crucial opportunity for care.

Concerns summary The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within 8 hours for patients on any anticoagulant, leading to delayed diagnosis.

Concerns summary The Trust's internal report was contradicted by inquest evidence, highlighting a gross failure in foetal heart rate monitoring during labour. Concerns remain about current training and the use of incorrect guidelines in maternity units.

Concerns summary Concerns remain about the implementation of NG tube policy changes and staff competency reassessment. Policy variations to reduce x-ray exposure led to confusion about the need for confirmation, risking tube misplacement.

Concerns summary Paramedics failed to document a patient's refusal of hospital admission, the advice given, or to provide information to her family or GP, leaving a vulnerable patient unmonitored.

Concerns summary Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.

Concerns summary The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.

Concerns summary Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.

Concerns summary A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.

Concerns summary The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.

Concerns summary Residents with cognitive illnesses in independent living flats could leave the building unnoticed due to unlocked doors and lack of foyer observation. The environment was unsuitable for confused residents, posing a wandering risk.

Concerns summary The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.

Concerns summary Patient information leaflets for SSRIs lack immediate, high-impact warnings, such as a "Black Box Warning," to clearly highlight the increased risk of suicidal thinking in young adults.