2020

Concerns summary Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.

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 Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.

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.

Concerns summary Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.

Concerns summary Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and posing a foreseeable risk of drawing individuals into self-harm.

Concerns summary Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and patients. Nursing agencies failed to share health vulnerabilities.

Concerns summary There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.

Concerns summary Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.

Concerns summary A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between local authorities.

Concerns summary Failures included inadequate risk assessment for delivery, incorrect forceps use due to insufficient training, excessive force, poor locum staff management, communication breakdowns, and unsuitable resuscitation equipment in maternity.

Concerns summary Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.

Concerns summary The care home failed to conduct a robust investigation into a resident's fatal fall, missing crucial learning opportunities to prevent similar incidents for other residents.

Concerns summary Concerns arose from a significant delay in applying an external fixator and an apparent failure to mobilise the patient, indicating potential lapses in clinical care.

Concerns summary Obstructed driver views, a Pelicon crossing located after a high-speed zone, and high non-compliance with traffic signals at the crossing create a dangerous environment for pedestrians.

Concerns summary Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve awareness and earlier diagnosis has not been implemented.

Concerns summary A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the overdose history during repeat prescription authorization, lacking critical scrutiny.

Concerns summary Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.

Concerns summary Nursing home staff provided an insufficient response to a high-fall-risk dementia patient, failing to account for his communication difficulties. Additionally, poor and unreliable record-keeping compromised accurate care narrative and incident review.

Concerns summary Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.

Concerns summary Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.

Concerns summary There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in delivery suites hinders contemporaneous observation recording.

Concerns summary A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.

Concerns summary The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.

Concerns summary Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to share Listeria isolates, hindering timely outbreak identification.