2020

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 Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between medication charts and actual stock.

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 GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that could have saved their life.

Concerns summary The DLR emergency response system is overly complex, requiring multiple steps for passengers to activate, and relies heavily on the public to notice and report track hazards, as CCTV cannot monitor all areas simultaneously.

Concerns summary The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.

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 Inadequately lit, carpeted steps at the venue were difficult to recognise, posing a fall hazard, particularly for those with poor eyesight, with no evidence of post-accident safety examination.

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.

Concerns summary Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.

Concerns summary Concerns were raised regarding the conduct, investigation, and conclusions made by the HSIB.

Concerns summary The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.