2020

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 The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.

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 Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not administered, potentially contributing to the baby's death.

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 The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health conditions.

Concerns summary A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.

Concerns summary Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.

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.

Concerns summary Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.

Concerns summary Current DVLA regulations for driving licences following epileptic seizures may need review, as a driver potentially experiencing a seizure lawfully held a licence, leading to a fatal incident.

Concerns summary Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance created significant safety risks.

Concerns summary Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.

Concerns summary A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic death.