2021

Concerns summary An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.

Concerns summary The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.

Concerns summary The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.

Concerns summary Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.

Concerns summary Inadequate monitoring and care planning for a deteriorating patient, alongside an unimplemented action plan for severe pancreatitis, raise concerns about ITU admission criteria driven by capacity, not clinical need.

Concerns summary Inadequate patient examination, a lack of documented medical reviews despite nurse bleeps, and confusing, suboptimal medical records indicate systemic failures in patient care and information management.

Concerns summary The Child & Adolescent Mental Health Centre lacked protocols for Mental Health Act assessments and failed to create an adequate safety plan with clear responsibilities and contingencies for non-attending patients. Crucially, relevant information about a suicide attempt was not fully shared, and police advice didn't account for absconding history.

Concerns summary Significant delays occurred in obtaining urgent lumbar puncture results and starting antiviral treatment. Additionally, post-liver biopsy observation protocols were not followed due to miscommunication and poor record-keeping.

Concerns summary Inaccurate and incomplete clinical information was conveyed during a HEMS dispatch call, with critical patient parameters omitted, potentially due to a lack of shared training or checklists between paramedics.

Concerns summary A patient's suicide risk was inappropriately downgraded by staff unfamiliar with their history, despite ongoing concerns from the care coordinator and a recent suicide attempt.

Concerns summary Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity in observation levels, suboptimal note-keeping, and insufficient daily reassessment of falls risk.

Concerns summary Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.

Concerns summary The non-standardised colour coding and varied types of breathing system filters create widespread confusion among ICU staff. This lack of simplification and standardisation risks incorrect filter usage and patient safety.

Concerns summary Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There is a need for improved training on mental welfare procedures.

Concerns summary The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.

Concerns summary There is a gap in enforcement powers to effectively address fire risks in residential properties, specifically concerning fire loads arising from hoarding behavior.

Concerns summary Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises risk assessments and specialist care.

Concerns summary Insufficient patient education materials regarding opioid tolerance loss and associated toxicity risks are a concern, particularly after periods of abstinence.

Concerns summary Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation efforts.

Concerns summary HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.

Concerns summary Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment for emergency contact, unchecked utilities, and inadequate social worker training on home suitability checks.

Concerns summary Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.

Concerns summary Inaccurate computer coding for medical procedures and a lack of auditing or quality control for data input raises concerns about the reliability of patient information.

Concerns summary Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.

Concerns summary The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.