2022

Concerns summary There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.

Concerns summary Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to recognise and respond to cardiac arrest.

Concerns summary Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.

Concerns summary Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of future vehicle collisions and potential loss of life.

Concerns summary The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.

Concerns summary The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.

Concerns summary Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for future lockdown scenarios.

Concerns summary Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.

Concerns summary While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary care.

Concerns summary National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.

Concerns summary High suicide rates among health service professionals require broader attention and action beyond existing support to prevent future deaths in this vulnerable professional group.

Concerns summary A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.

Concerns summary Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.

Concerns summary Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.

Concerns summary Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.

Concerns summary Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.

Concerns summary Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration concerns.

Concerns summary Concerns include a midwife being dissuaded from a necessary procedure, leading to delivery delays, inadequate fetal monitoring, and a lack of pre-labour birthing option discussions. "Normal birth" language on checklists is also concerning.

Concerns summary Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its potential for varied abuse.

Concerns summary There is a critical lack of specific guidelines for the optimal management of fatal fetal infection, leaving clinicians without assistance in situations like circulatory collapse at birth.

Concerns summary Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.

Concerns summary Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing timely ambulance clearance.

Concerns summary Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate community support and clinical rationale.

Concerns summary Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted as "okay," indicating a lack of clear policies and training for observation management.

Concerns summary There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for the "Seven-day short stay booklet for admission/discharge."