2020

Concerns summary There was a systematic failure to refer a patient with severe pressure sores and high-risk factors to a Tissue Viability Nurse. This was compounded by a lack of clear guidelines for TVN referrals and involvement in prevention plans.

Concerns summary Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk management and leave authorization. Decision-making for self-discharge and Mental Health Act detention also lacked sufficient senior input.

Concerns summary Hospital bed rails were found to be unsafe, allowing a patient to fall. Additionally, the definition, administration, and training for one-to-one care were inadequate, risking patients being left unattended.