2020

Concerns summary The report vaguely mentions that issues leading to patient falls in the Emergency Department are a "wider national issue," but provides no specific details on remaining concerns or identified risks.

Concerns summary Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.

Concerns summary An unlit dual carriageway with a national speed limit, lacking a footpath, is extremely unsafe for pedestrians. Visibility for drivers was inadequate, making emergency stops impossible within the available range.

Concerns summary Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and risking critical issues being missed.

Concerns summary The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not adequately reassessed.

Concerns summary Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.

Concerns summary A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays in other cases could result in preventable deaths.

Concerns summary Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.

Concerns summary A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for those traversing both carriageways.

Concerns summary The GP practice suffered from insufficient GPs, a poor escalation process for nurses, and inadequate recognition of a patient's risks. Poor medical notes and long-standing local concerns about the practice were also noted.

Concerns summary The patient experienced unacceptable delays in medical assessment and receiving critical IV fluid and antibiotic treatment, preventing any chance of survival.

Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.

Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.

Concerns summary A lack of clear pathways for dysphagia and a missed opportunity to investigate for malignancy, alongside poorly completed fluid balance charts that failed to identify a critical fluid overload, contributed to the death.

Concerns summary Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.

Concerns summary Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted patient safety. Additionally, the patient's capacity was misunderstood, and an unsuitable placement led to falls and injury.

Concerns summary The ward suffered from long-term understaffing, reliance on agency staff, and delays in discharge due to lack of community care. Poor documentation, failure to follow falls policy, and insufficient consultant reviews also meant deterioration went unescalated.

Concerns summary Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare provision compared to England.

Concerns summary Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. Staff also failed to document or risk-assess a resident's habit of ingesting non-food items, leading to an incomplete understanding of risk.

Concerns summary The legal framework for "blood bike" volunteers' use of emergency vehicle exemptions (blue lights, speed limits) for routine courier services appears unclear, potentially leading to unsafe practices or misapplication of regulations.

Concerns summary There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, hindering optimal integrated care.

Concerns summary Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of preventable deaths.

Concerns summary No specific concerns were detailed in the provided text for this report beyond a general statement of risk.

Concerns summary Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical observation recording, and staff confusion regarding oxygen administration and mandatory training.

Concerns summary Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical lack of regular clinical observations for a seriously unwell patient.