2021

Concerns summary Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.

Concerns summary Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns summary Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID wards, a risk potentially unresolved in other trusts.

Concerns summary A telephone-only GP consultation missed DVT, an abnormally high D-Dimmer failed to alert on the electronic system, and national guidance lacks COVID-19 specific clot risk management.

Concerns summary The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures for high-risk elderly patients.

Concerns summary Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits hindered comprehensive risk assessment and family involvement.

Concerns summary National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across trusts.

Concerns summary Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.

Concerns summary There was no multi-agency planning or established procedures for the safe discharge of patients with complex concurrent mental health, substance misuse, social care, and physical health needs.

Concerns summary The lack of a designated referral pathway and national guidelines for achondroplasia means general paediatric teams are often unaware of associated sudden infant death risks, such as foramen magnum stenosis.

Concerns summary Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.

Concerns summary The provided text is incomplete and does not contain specific concerns for summarization.

Concerns summary Concerns about an individual's professional practice were not referred to the relevant professional body in a timely manner. This delay in addressing competence issues poses a risk to future patients.

Concerns summary A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.

Concerns summary Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.

Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.

Concerns summary A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.

Concerns summary GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an adequate mental health risk assessment; internal reviews also failed to identify these critical errors.

Concerns summary The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.

Concerns summary Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and poor record-keeping by senior staff.

Concerns summary There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.

Concerns summary Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.

Concerns summary An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing the driver's view of a cyclist.