2020

Concerns summary The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.

Concerns summary The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.

Concerns summary Concerns include inadequate patient consent processes, with explanations given minutes before major surgery, and nursing staff failing to consistently escalate monitoring or seek clinical review after non-reassuring vital signs.

Concerns summary There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.

Concerns summary The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly assess or manage the risk posed by an aggressive resident, leading to an assault and neglect of head injury monitoring.

Concerns summary Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed risks to patient safety.

Concerns summary Critical failures include outdated care plans, poor record-keeping and information compilation, lack of psychiatrist reviews, inconsistent risk assessment policies, and inadequate handover procedures, all contributing to a fragmented care system.

Concerns summary Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.

Concerns summary Lorries lacked essential safety features like hand holds for driver access and necessary equipment (CO2 detectors, telescopic mirrors) for Border Force checks, tempting drivers to use unsuitable alternatives.

Concerns summary An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making staff, indicating no system for clear documentation and accountability in clinical triage.

Concerns summary Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.

Concerns summary Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.

Concerns summary A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.

Concerns summary The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.

Concerns summary Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.

Concerns summary The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.

Concerns summary Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.

Concerns summary The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.

Concerns summary Inadequate and poorly located beach signage, insufficient surveillance, and lack of warnings contributed to fatalities, suggesting a need for improved information boards and increased beach patrol presence.

Concerns summary Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.

Concerns summary Easy public access to a restricted dam, inadequate signage, and exposed live wiring led to an electrocution, with no explanation or report on building regulations enforcement provided.

Concerns summary A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.

Concerns summary Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.

Concerns summary The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, leading to disputed treatment.

Concerns summary A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid protocol adherence, creating a significant gap in supervision for vulnerable individuals falling between service remits.