2020

Concerns summary The hospital failed to conduct a Serious Untoward Incident investigation, and its emergency department lacked a rapid assessment model, causing significant delays in senior doctor assessment and critical treatment for walk-in patients.

Concerns summary Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication with care providers. Patient monitoring was also insufficient, and CPR wasn't initiated when warranted.

Concerns summary Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.

Concerns summary Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.

Concerns summary Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.

Concerns summary The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.

Concerns summary A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full assessment, indicating a need for procedure review and revision.

Concerns summary The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.

Concerns summary Hospital staff repeatedly failed to check a patient's literacy during admission and discharge, leaving her unable to read critical written instructions. This systemic failure risks patients not understanding vital care information.

Concerns summary Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical history was unavailable. This created significant risks for vulnerable patients, hindering comprehensive assessment.

Concerns summary An elderly patient remained in acute care for weeks post-medical optimisation due to a severe lack of suitable EMI placements. This delayed discharge and inappropriately occupied an acute hospital bed.

Concerns summary An elderly, vulnerable patient received inadequate care in an overcrowded Emergency Department, including being treated in a corridor. Significant delays for critical procedures and surgical ward transfer were caused by bed capacity issues.

Concerns summary The deceased accessed Dinitrophenol (DNP), a drug banned in the UK since 1938 due to its harmful effects, via the internet, likely influenced by social media, leading to his overdose.

Concerns summary No specific concerns were detailed in the provided text for this report.

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 A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals in other cases, although it did not affect this specific patient's treatment.

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 The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary responsibility on the driver to inform the DVLA rather than mandating direct clinical referral.

Concerns summary The junction is considered unsafe due to a history of collisions and concerns regarding the safety of vehicles performing U-turn maneuvers across the carriageway to a central reservation.