2021

Concerns summary Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting observations lacked professional regulatory oversight.

Concerns summary Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening for soldiers outside their chain of command were identified.

Concerns summary The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.

Concerns summary Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.

Concerns summary There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the community and when a mandatory referral to a pain specialist is required.

Concerns summary The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.

Concerns summary Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.

Concerns summary Current regulations for Crash Resistant Fuel Systems (CRFS) in rotorcraft are inadequate, failing to mandate retrofits or provide a public register. This leaves a high risk of post-crash fires and prevents informed public decision-making.

Concerns summary Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.

Concerns summary Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.

Concerns summary Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There was also confusion and a lack of coordination during CPR efforts.

Concerns summary There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.

Concerns summary There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.

Concerns summary The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.

Concerns summary The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.

Concerns summary University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.

Concerns summary The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.

Concerns summary NICE Guidance NG121 lacks a clear definition for "large-for-gestational-age" babies, leading to inconsistent interpretation and application of delivery mode guidance. This creates uncertainty in crucial obstetric care decisions.

Concerns summary Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.

Concerns summary The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific coroner's concerns regarding systemic failures or safety issues for future prevention.

Concerns summary There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack of specific guidance for managing infection risks associated with a retained deceased foetus following feticide.

Concerns summary A lack of mandatory radio communication between ground crew and glider pilots meant observed glider problems before launch were not communicated. This ongoing absence of mandatory radio use poses a future risk to lives.

Concerns summary The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's specific concerns regarding systemic failures or risks.

Concerns summary Excessive and prolonged patient handover delays at the hospital severely impacted ambulance response times, highlighting a critical national issue in emergency care.

Concerns summary Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of safety barriers or window restrictors created a significant fall risk in housing properties.