2021

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

Concerns summary Inadequate advice to an older driver and their family about driving risks associated with acute illness-induced confusion, combined with insufficient testing and guidance for older drivers, highlights a systemic road safety failure.

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 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 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 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 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 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 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 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 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 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 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.

Concerns summary Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management during air ambulance repatriations pose risks of future deaths.