2021

Concerns summary The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.

Concerns summary Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.

Concerns summary The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.

Concerns summary An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.

Concerns summary Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.

Concerns summary A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.

Concerns summary Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.

Concerns summary Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, posing a risk of misuse.

Concerns summary There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined responsibilities for guests.

Concerns summary Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.

Concerns summary Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to provide adequate care, particularly for vulnerable patients.

Concerns summary Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.

Concerns summary There is a lack of clarity between hospital and primary care regarding responsibility for monitoring antibiotic prescriptions, risking patient safety where GPs prescribe at hospital request.

Concerns summary Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home hindered proper assessment of changing patient conditions.

Concerns summary Inadequate senior medical supervision for junior doctors in the Emergency Department, particularly at night, and inconsistent documentation of clinical discussions pose significant risks to patient care.

Concerns summary Significant delays in gynaecology referrals, poor understanding of NICE guidance in General Practice, inadequate GP referral documentation, and a lack of follow-up systems for referrals hindered effective patient care and risk identification.

Concerns summary Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.

Concerns summary The care home failed to adequately prevent pressure damage for a vulnerable resident and identify their deteriorating condition. Frontline staff lacked crucial training, and senior management showed a culture of obfuscation.

Concerns summary CTG monitoring equipment obscured vital graphic data, and key medical staff lacked up-to-date mandated annual CTG training, highlighting systemic failures in equipment design and training compliance.

Concerns summary Social services struggled to properly investigate safeguarding referrals, appoint social workers within a reasonable timeframe, or conduct timely home suitability assessments for vulnerable residents.

Concerns summary The NHS lacks a system for tracking non-cancer outpatient appointments, unlike cancer cases. Implementing such a system could prevent unnecessary deaths and improve administrative efficiency.

Concerns summary A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.

Concerns summary Staff failed to understand and address confirmation bias, hindering practice changes. Inadequate and slow training on this issue leaves mothers and babies at continued risk.

Concerns summary The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.

Concerns summary The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.