2021

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 Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.

Concerns summary A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.

Concerns summary The provided text indicates general concerns exist that risk future deaths, but does not detail the specific issues or systemic failures identified by the coroner.

Concerns summary Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.

Concerns summary Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.

Concerns summary Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.

Concerns summary A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising against proper record-keeping and a general lack of trust cooperation with the inquest.

Concerns summary The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.

Concerns summary The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.

Concerns summary The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.

Concerns summary Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.

Concerns summary The Crisis Resolution Home Treatment Team prioritized avoiding hospital admission over life protection and over-relied on the patient's denial of suicidal intent. The Trust's investigation was inaccurate and inadequate.

Concerns summary Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.

Concerns summary The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.

Concerns summary An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.

Concerns summary An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar trailers remain in use without these critical safety features, posing a risk of future accidents.

Concerns summary Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.

Concerns summary Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.

Concerns summary Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.

Concerns summary The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.

Concerns summary The CQC's failure to routinely check window restrictors, combined with a nursing home's un-manned weekend reception, allowed residents without capacity to leave unaccompanied, posing a significant risk.

Concerns summary The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially with a filter. A more robust docking mechanism is needed to prevent inadvertent disconnections.

Concerns summary Safety signs prohibiting swimming were obscured by vegetation and were old, making them less noticeable and explicit about the dangers of the water.