2022

Concerns summary An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of concerns. There was also a lack of follow-up for this remote prescribing.

Concerns summary The patient was inappropriately allocated a low falls risk, and crucially, the subsequent Root Cause Analysis and senior staff initially failed to recognise this error. This suggests a significant lack of learning and potential flaws in policy understanding or the policy itself.

Concerns summary Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.

Concerns summary Insufficient weekend doctor staffing led to delayed face-to-face review for a sepsis-triggering patient, causing the seriousness to be unrecognised and the sepsis policy to be un-followed. The failure to escalate concerns was unclear.

Concerns summary Persistent bed shortages caused elderly hip fracture patients to endure lengthy Emergency Department waits, hindering timely orthogeriatric care and preventing surgery within NICE guideline timescales. This impacts patient outcomes and mortality.

Concerns summary Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist nurse service's role was also poorly understood by community healthcare providers.

Concerns summary There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.

Concerns summary There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure to progress critical steps like a warrant, delaying further intervention.

Concerns summary There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.

Concerns summary The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious local systemic issue.

Concerns summary A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.

Concerns summary A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of bus and coach driver training.

Concerns summary A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and crucial information not being disclosed.

Concerns summary Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.

Concerns summary The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.

Concerns summary The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and tenant certificates are misleading.

Concerns summary Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially impacting care decisions and safety measures.

Concerns summary A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down cyclists or pedestrians. This design creates a high collision risk, particularly for children.

Concerns summary A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without awareness of the patient's history.

Concerns summary A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.

Concerns summary The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Concerns summary Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.

Concerns summary The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.

Concerns summary Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services attend.

Concerns summary The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.