2022

Concerns summary Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and training review.

Concerns summary The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.

Concerns summary The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed re-assessments, resulting in lost learning opportunities and compromised patient safety.

Concerns summary A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.

Concerns summary Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to a patient's concerns being overlooked before an inappropriate discharge.

Concerns summary The ward's inadequate layout hindered patient observation. Inexperienced staff, lacking clear protocols for senior review, conducted inadequate risk assessments, leaving vulnerable patients unattended after trigger events.

Concerns summary Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational age babies.

Concerns summary An untrained call handler failed to properly escalate a critical call, leading to inadequate action despite receiving important information. There was a systemic failure to appropriately handle and discuss the case.

Concerns summary A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths from high-speed driving.

Concerns summary Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a lack of understanding of resident needs and falls policies.

Concerns summary An inexperienced worker was left unsupervised with poorly maintained Fork Lift Trucks lacking critical safety devices. The company demonstrated a profound lack of health and safety understanding and failed to implement changes years after the death.

Concerns summary Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to vulnerable patients.

Concerns summary The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or provide fixed overdose treatment training for doctors.

Concerns summary Prison healthcare failed to follow up on significant discrepancies between a prisoner's self-reported mental health and his GP records, particularly concerning past suicide attempts, leaving him vulnerable in early custody.

Concerns summary The public lacks crucial understanding and awareness regarding their responsibility to report motorway incidents, despite existing SMART motorway campaigns, leaving stationary vehicles a significant hazard.

Concerns summary Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.

Concerns summary Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.

Concerns summary Extended surgery wait times due to COVID backlogs and severe ambulance availability issues led to significant delays in critical care, causing distress and impacting patient outcomes.

Concerns summary Prolonged waits in the Emergency Department due to bed shortages and delays in essential surgery due to theatre capacity severely impacted the patient's physiological reserves and overall outcome.

Concerns summary There was a critical systemic failure in inter-agency communication, leaving a vulnerable person's relocation unknown to social services and without oversight of the quality of her private care arrangements.

Concerns summary Critical failures included a chaotic cardiac arrest response, non-escalation of elevated blood pressure, lack of VTE risk assessment, and unreviewed chest pain. Misinformation regarding a DNACPR was also not promptly admitted.

Concerns summary The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.

Concerns summary Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with epistaxis or facial fractures, potentially missing continued bleeding.

Concerns summary A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral haemorrhage.

Concerns summary There was a missed opportunity to provide timely care and treatment to the deceased before she was found in extremis.