2021

Concerns summary Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.

Concerns summary Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.

Concerns summary Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.

Concerns summary A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.

Concerns summary A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.

Concerns summary Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially with increasing severe rainfall.

Concerns summary There's been an concerning increase in severe nutritional anaemia and related deaths in children, potentially due to reduced health consultations, limited social contact, and widening socio-economic inequalities exacerbated by the pandemic.

Concerns summary Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.

Concerns summary Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.

Concerns summary Following forced police entry, an occupied house was left with its main exit boarded up and the secondary exit unusable, creating a significant fire safety risk by denying residents alternative escape routes.

Concerns summary Mental health wards fail to effectively communicate "restricted items" policies to families, leading to inadvertent rule breaches and hindering family support for patient safety.

Concerns summary A lethal gas risk in transformers was unrecognised due to inadequate warnings, missing manufacturer guidance on safe oil levels, and lack of recommended maintenance.

Concerns summary A lack of authoritative national guidance for assessing gastroenteritis, dehydration, and the need for face-to-face reviews in patients over 70 poses a risk.

Concerns summary Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer patients to crisis teams.

Concerns summary A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy led to chaotic team malfunction during a critical emergency.

Concerns summary A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, or detection for at-risk individuals.

Concerns summary Inadequate staffing, poor call bell response times, and a systemic failure to complete falls risk assessments for vulnerable patients compromise safety across hospital wards.

Concerns summary Inadequate skin integrity assessments occurred in A&E for prolonged stays, and staff failed to seek external professional advice for managing patient resistance to turning.

Concerns summary Elderly individuals can acquire mobility scooters without any assessment of their suitability or competence to use them, posing a significant safety risk.

Concerns summary Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, and the manufacturer has not provided a solution.

Concerns summary Inadequate guidance exists for managing fire risk in supported accommodation for vulnerable residents, exacerbated by no statutory sprinkler requirement and ineffective smoke detector placement.

Concerns summary Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage instructions, posing a significant risk.

Concerns summary A systemic failure in a care home led to inadequate and unrecorded skin inspections for a frail resident over multiple days, posing a significant risk to vulnerable patients.

Concerns summary Pandemic restrictions led to inadequate support for a vulnerable patient in outpatient settings and limited post-discharge monitoring, hindering accurate assessment and timely recognition of deteriorating health.

Concerns summary Pandemic-era telephone consultations and unsupported solo hospital visits for a vulnerable patient led to missed physical examinations and incomplete information. There is no specific NICE guidance for elderly femur fracture management.