2022

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 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 Inadequate nursing observation, delayed emergency response due to perceived safety risks, and unfamiliarity with resuscitation equipment by the sole junior doctor contributed to a critical delay.

Concerns summary The Trust failed to conduct a detailed investigation into serious clinical incidents, submitted a flawed incident report, and showed a lack of understanding in applying the Mental Capacity Act 2005 for patients with learning disabilities.

Concerns summary CPR advice for agonal breathing in a collapsed, intoxicated person on their side led to aspiration and cessation of breathing upon turning. This highlights a need for clearer guidance on managing such scenarios.

Concerns summary Inadequate safety measures on a popular bridge and surrounding area fail to deter dangerous activities by teenagers, creating a risk of future tragedies.

Concerns summary Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training for medical professionals contributed to a preventable death.

Concerns summary Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.

Concerns summary The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person plan in place.

Concerns summary A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. Signs of sepsis were missed, and no surgical opinion was sought post-discharge.

Concerns summary Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to difficulties in charting wound progress and providing correct care.

Concerns summary Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.

Concerns summary Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.

Concerns summary Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.

Concerns summary Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family involvement, and breaches of the Enhanced Care Policy.

Concerns summary Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.

Concerns summary Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.

Concerns summary The existing falls policy is non-compliant with NICE guidelines, lacks a designated lead, and critical staff training and assisted technology for patient falls prevention are significantly delayed.

Concerns summary A specific road section is dangerously prone to severe surface water accumulation due to inadequate drainage and poor design, creating a high risk of accidents exacerbated by a lack of warning signs. Permanent engineering changes are critically needed.

Concerns summary The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic steps.

Concerns summary Vulnerable young people face dangerously long waiting lists (over a year) for psychological therapy and specialist services like the Gender Identity Clinic, leaving a critical gap in support between urgent and non-urgent mental health interventions.

Concerns summary Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor clinical documentation compromising patient safety.

Concerns summary Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor record-keeping and communication, an incomplete incident action plan, and no regulatory referral for staff failings.

Concerns summary Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.