2020

Concerns summary The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.

Concerns summary The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.

Concerns summary Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.

Concerns summary The Commissioner failed to authorise essential 1:1 care for a patient at high risk of falls, despite it being the only identified method to mitigate her specific risks.

Concerns summary The absence of a national database for gas appliances hinders rapid identification and tracing of dangerous items. Lack of mandatory recording impedes urgent communication and tracing between stakeholders.

Concerns summary Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.

Concerns summary Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.

Concerns summary Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.

Concerns summary Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent station security measures when unstaffed.

Concerns summary Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.

Concerns summary Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.

Concerns summary The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe incidents.

Concerns summary Safe sleeping advice was inadequately communicated to both parents, and reduced health visitor services during the pandemic further compromised support for new parents.

Concerns summary The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.

Concerns summary Critical consultant advice on a complex medical situation was neither recorded in writing nor confirmed, risking misunderstandings between medical teams.

Concerns summary Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential sepsis creates future death risks.

Concerns summary A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.

Concerns summary Repeated misdiagnoses occurred at the hospital, despite clear GP instructions, due to systemic failures in accessing electronic patient records and slow scanning of notes.

Concerns summary Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.

Concerns summary Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.

Concerns summary A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.

Concerns summary Toxic substances are easily and cheaply obtainable online without safeguards, and are advocated on websites as a method for suicide, leading to multiple deaths.

Concerns summary A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a second opinion, highlighting a critical lack of safeguards in risk assessment.

Concerns summary The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated safe zones for drivers, and insufficient equipment for handling large products.

Concerns summary Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and urgent mental health assessments.