2021

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 Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.

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 There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking patient safety where GPs prescribe at hospital request.

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 Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety Units face significant workload pressures impacting safeguarding effectiveness.

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 Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. Despite repeated warnings and notices issued since 2015, in-cell automatic fire detectors remain uninstalled.

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 High reliance on agency nursing staff raises concerns about consistent training and continuity of care. The national shortage of nursing staff contributes to these systemic challenges.

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.

Concerns summary Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home hindered proper assessment of changing patient conditions.

Concerns summary The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.

Concerns summary A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.

Concerns summary Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of clinical discussions pose significant risks to patient care.