2021

Concerns summary A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.

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 Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.

Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.

Concerns summary A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.

Concerns summary There is an urgent need for specialist dual diagnosis services with outreach facilities for individuals experiencing mental health crises intertwined with substance abuse, who are often denied adequate support.

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 GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an adequate mental health risk assessment; internal reviews also failed to identify these critical errors.

Concerns summary The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.

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 Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and poor record-keeping by senior staff.

Concerns summary Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.

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.

Concerns summary Concerns involve potential under-reporting of PEG allergy, insufficient research into its effects, and the lack of clear labelling on medical products regarding PEG's presence, dose, and various synonyms.

Concerns summary The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no tracking mechanism for unprogressed cases.

Concerns summary The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.

Concerns summary Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.

Concerns summary Staffing levels at the care home were below minimum requirements for one-to-one care, and record-keeping standards remained inadequate and inaccurate, despite prior concerns.