2020

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 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.

Concerns summary Deficient initial critical analysis of child deaths masked significant failings, preventing crucial learning, and an unsafe culture within Midwifery Services disregarded staff safety concerns.

Concerns summary An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for robust driver referral schemes to take unsafe drivers off the road.

Concerns summary The absence of professional guidance and training for midwives performing vaginal pushes during fetal extraction, alongside inconsistent use of fetal pillows, contributed to a fetal head injury.

Concerns summary The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.

Concerns summary Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, hindering safeguarding due to a lack of inter-agency sharing.

Concerns summary Delayed neurosurgical input, absence of a fast-track system for critical CT scans for warfarin patients, and insufficient follow-up of haematology advice led to significant care delays.

Concerns summary Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.

Concerns summary Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.

Concerns summary Confusing "SLOW" road markings on a 60mph road and a lack of warning signs or hazard lines on a bend with reduced visibility created a dangerous road environment.

Concerns summary The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.

Concerns summary Systemic delays in scheduling cardiology tests and subsequent patient referrals to specialists caused significant backlogs, hindering timely diagnosis and treatment.

Concerns summary Acute hospital bed shortages forced frail patients through lengthy A&E waits, leading to deconditioning, compounded by significant delays in arranging post-discharge care packages.

Concerns summary Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.

Concerns summary Hospital staff lacked familiarity with morphine guidelines, used outdated policies, received inadequate training, and experienced communication failures preventing a nurse from challenging a dangerous prescription.

Concerns summary Indistinctive packaging for IV fluids used in arterial lines causes confusion, while medical staff's incorrect blood sampling technique from arterial lines further exacerbated errors.

Concerns summary Anticoagulant prescription errors remain unexplained, indicating a risk of recurrence due to muddled documentation, lack of senior review, and absence of a clear prescription plan for staff.

Concerns summary Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for emergency medical assistance.

Concerns summary Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.

Concerns summary An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction entries in medical records.

Concerns summary The absence of statutory international criminal background checks allows unsuitable individuals with foreign convictions to work with vulnerable adults and children, posing a significant risk.

Concerns summary Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service resources.