2022

Concerns summary (AI summary) Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. There was also no documented evidence of information provided to the patient.

Concerns summary (AI summary) Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.

Concerns summary (AI summary) There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.

Concerns summary (AI summary) A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks premature discharge and insufficient information for families on signs of concern.

Concerns summary (AI summary) A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.

Concerns summary (AI summary) Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also hindered family advocacy.

Concerns summary (AI summary) Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.

Concerns summary (AI summary) There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in a patient with complex needs being sent to unsuitable accommodation against clinical recommendations.

Concerns summary (AI summary) There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.

Concerns summary (AI summary) There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.

Concerns summary (AI summary) Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.

Concerns summary (AI summary) Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.

Concerns summary (AI summary) A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.

Concerns summary (AI summary) Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.

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

Concerns summary (AI summary) The report identifies concerns that a midwife was talked out of seeking support for an episiotomy, leading to delays and inadequate monitoring, and that there was a lack of discussion with the patient about birthing options prior to labour.

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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.