2022

Concerns summary Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a significant risk to patient safety.

Concerns summary Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.

Concerns summary Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to compromised care.

Concerns summary There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.

Concerns summary Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no registered landlord scheme or enforcement powers.

Concerns summary Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or incapacitation.

Concerns summary The absence of a single 'Event Organiser' for public events hinders safety planning and risk management, as authorities lack legal powers to mandate an organiser or refuse unsafe events.

Concerns summary Delays in urgent fetal growth scans due to capacity issues, coupled with a lack of widespread understanding of fetal growth restriction risks, compromise timely intervention and parental awareness.

Concerns summary Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.

Concerns summary The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.

Concerns summary The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails at the time of a fatal fall, indicating a potential ongoing risk.

Concerns summary The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.

Concerns summary System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and critical patient observations were not recorded or conveyed to specialists.

Concerns summary "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.

Concerns summary Deficient safeguarding reviews and clinical oversight, combined with a lack of staff awareness, training, and audit of the VTE policy, created significant patient risks.

Concerns summary In effective bin locks and the absence of an automated weight flagging system failed to detect an individual in a bin, further compounded by poor driver visibility and inadequate search tools.

Concerns summary Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.

Concerns summary Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services in the North Warwickshire area.

Concerns summary GPs lack specific guidance for managing complex eating disorders, especially when patients are unwilling to engage, leading to uncertainty in treatment. There is also a concern regarding counselling guidance when patients are unwilling to engage.

Concerns summary Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.

Concerns summary There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order should not be applied.

Concerns summary Smart motorways with no hard shoulder create risks for broken-down vehicles, compounded by occupant proximity to running lanes and confusion from mixing smart and traditional motorways.

Concerns summary Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.

Concerns summary The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.

Concerns summary Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.