2022

Concerns summary The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, inadequate resident supervision during meals, and absence of post-hospital admission risk assessments.

Concerns summary Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were issues with task allocation, record keeping, and ensuring staff safely enter rooms for patient welfare checks.

Concerns summary Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of death and confusion regarding DNAR status.

Concerns summary The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, and self-harm incidents lacked debriefs to inform future risk assessments.

Concerns summary Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information sharing and holistic patient views.

Concerns summary The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown in properly recording and communicating the care plan with the family.

Concerns summary The Trust failed to formally refer a doctor who misappropriated medicines for self-harm to external authorities (police, GMC), and did not reconsider its position when he continued private practice. A critical lack of multi-disciplinary review, relying on the medical hierarchy, was noted given the gravity and prior similar cases.

Concerns summary A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to confusion, unclear communication, and misperceptions of authority. This created a significant safety risk, despite not directly contributing to these deaths.

Concerns summary Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.

Concerns summary The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to a crucial falls risk assessment not being updated after multiple falls, increasing future risk.

Concerns summary Significant delays in doctors reviewing crucial blood test results and consulting a gastroenterologist led to late commencement of steroid therapy and delayed liver transplant referral, hindering timely and effective care.

Concerns summary Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.

Concerns summary Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.

Concerns summary Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person follow-up before discharge, and urgent weekend referrals were not triaged.

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 was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.

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 Significant delays in a hip fracture patient's care were caused by a shortage of cardiologists, particularly during weekends, and further compounded by theatre capacity and High Dependency Unit bed shortages.

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.