2021

Concerns summary Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.

Concerns summary The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.

Concerns summary There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.

Concerns summary Widespread and continuing lack of training, knowledge, and experience among medical professionals regarding eating disorders, coupled with a severe shortage of specialists, risks future deaths.

Concerns summary There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental health teams.

Concerns summary The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.

Concerns summary The M1 'Managed Motorway' section lacks a hard shoulder, creating a significant risk of future deaths when vehicles experience mechanical defects and cannot pull into a safe place.

Concerns summary The emergency medical dispatch protocol inadequately recognised life-threatening asthma symptoms, and the ambulance service consistently failed to meet Category 2 response time targets.

Concerns summary The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.

Concerns summary Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.

Concerns summary The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform the DVLA.

Concerns summary Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not mandate crucial mitigating measures like cameras or banksmen.

Concerns summary The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.

Concerns summary A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.

Concerns summary Medical teams failed to recognise total body potassium depletion in a child with myopathies, leading to insufficient treatment for his complex needs in a standard ward setting.

Concerns summary The ambulance service's delayed response to a time-sensitive paracetamol overdose exceeded 3 hours, arriving too late for effective treatment.

Concerns summary The concerns text provided is incomplete and does not specify any particular safety issues or systemic failures.

Concerns summary Drivers fail to notice a roundabout approached from a bend, indicating a need for further engineering solutions like rumble strips to provide additional warnings.

Concerns summary Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was ineffective safety officer monitoring, poor leadership and risk assessment during restraint, and insufficient paramedic input.

Concerns summary There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.

Concerns summary The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.

Concerns summary Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and abnormal vital signs. Unclear escalation procedures and inadequate staff training risk similar future incidents.

Concerns summary There was a complete failure in falls prevention, with inadequate multidisciplinary management and insufficient supervision for a confused, agitated patient. Wards were dangerously understaffed, failing to provide required enhanced care levels.

Concerns summary National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.

Concerns summary The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening door could have prevented the death.