2021

Concerns summary National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls and contracting nosocomial infections.

Concerns summary The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously ill prisoner to hospital.

Concerns summary A chronic and long-standing shortage of essential falls alarm equipment at the hospital significantly increases patient risk of falls and fatal injuries, compromising staff's ability to provide safety.

Concerns summary There is an inadequate provision of mental health support for prison officers, which needs urgent review.

Concerns summary Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.

Concerns summary A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.

Concerns summary The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, needs to be confirmed and any partial implementation justified.

Concerns summary National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.

Concerns summary Product description for a 14Fr feeding/drainage tube was misleading due to a restrictive connector, leading to inadequate drainage. Hospital evaluation was insufficient, and staff lacked training on product changes and alternative actions.

Concerns summary An enteral feeding and drainage tube's product description and staff training were insufficient, leading to confusion about its reduced bore size. This caused inadequate drainage, and the product is still misleadingly promoted.

Concerns summary A high-risk patient with infection symptoms did not receive timely antibiotic intervention. There was no clear treatment plan, and the actual administration time for a critical antibiotic was not confirmed.

Concerns summary A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in use after an inspection.

Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.

Concerns summary A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.

Concerns summary The existing road layout and measures highlighting the kerb need review to ensure they meet safety regulations, particularly regarding the commencement of the kerb.

Concerns summary Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts due to time lost establishing who was missing.

Concerns summary The care home's business decision not to use pendant call alarms meant fixed call bells were often out of reach for falls-risk residents, increasing their injury risk.

Concerns summary A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.

Concerns summary The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.

Concerns summary There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals addicted to obtain large amounts despite fatal risks.

Concerns summary Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.

Concerns summary Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.

Concerns summary Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered an urgent cardiology referral.

Concerns summary The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.

Concerns summary Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.