2022

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 The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical input and limited learning from a serious event. Trust-wide policy review and comprehensive retraining are urgently required.

Concerns summary A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient knowledge, indicating severe systemic failures.

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.

Concerns summary Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs lacking clear guidance on escalating concerns.

Concerns summary There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.

Concerns summary A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.

Concerns summary A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, compounded by inadequate staff training.

Concerns summary There is a critical gap in dermatology commissioning for Royal Oldham Hospital inpatients, excluding those from outside the local area unless their skin condition becomes an emergency.

Concerns summary A poorly designed nearside cycle lane creates confusion and places cyclists in conflict with right-turning vehicles, exacerbated by the lane being narrower than recommended standards.

Concerns summary Sepsis protocols are outdated or unknown to staff, including new and agency clinicians, leading to concerns about inadequate training and lack of audits for timely recognition and treatment.

Concerns summary The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.

Concerns summary The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.

Concerns summary Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency identification, and safety information on labels is insufficient.

Concerns summary NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other naturally occurring conditions affecting blood clotting, leading to missed diagnostic opportunities.

Concerns summary Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a significant risk to public safety, particularly pedestrians in populated areas.

Concerns summary Emergency ambulance delays due to high demand and an incorrect call pathway led to an extended response time for a Category 2 call, raising concerns about future deaths despite service changes.

Concerns summary Significant delays in emergency ambulance response for a Category 2 call due to high demand led to a patient's deterioration, raising concerns about future deaths despite recent service improvements.

Concerns summary The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental health conditions and substance misuse issues.

Concerns summary Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy and staff confusion regarding powers to detain 'at-risk' patients lacking mental capacity.