2020

Concerns summary Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.

Concerns summary Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.

Concerns summary Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.

Concerns summary The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely and posing a significant risk to other road users.

Concerns summary Dangerous road conditions on the A66 include a lack of pedestrian warnings, rapid acceleration onto an unlit section, poor lighting, and national speed limit signs placed too close to a roundabout.

Concerns summary The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.

Concerns summary Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.

Concerns summary Incomplete patient records, difficulty contacting on-call medical staff, and a critical failure to refer the patient for post-discharge monitoring created significant care gaps.

Concerns summary The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.

Concerns summary Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.

Concerns summary Residential landlords are not required to inspect window coverings in private rental properties to ensure only safety cords are used, posing a risk of entanglement.

Concerns summary Reduced information sharing from the care home to hospital clinicians, partly due to family visiting restrictions, hindered the provision of accurate baseline health data, risking treatment delays for vulnerable patients.

Concerns summary Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.

Concerns summary Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.

Concerns summary Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary team consultation.

Concerns summary There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.

Concerns summary Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.

Concerns summary The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.

Concerns summary Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.

Concerns summary A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.

Concerns summary When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.

Concerns summary Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.

Concerns summary Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.

Concerns summary Failure to escalate a rare blood condition to specialists, an unrobust VTE assessment system, and unclear flagging of anticoagulation decisions on records posed significant risks.

Concerns summary Lack of formal transfer agreements and speciality doctor reviews in ED, coupled with widespread failures in vital signs observation, documentation, and medication recording, jeopardised patient safety.