2022

Concerns summary The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a serious incident.

Concerns summary Understaffed District Nursing impacted catheter care; the hospital failed to recognize significant learning difficulties, denying IMCA support. A local authority dispute also hindered catheter care training.

Concerns summary A radiographer's fracture report was not acted upon, leading to missed follow-up care. The Trust failed to investigate this lapse, missing critical opportunities for learning and systemic improvement in acting on abnormal imaging.

Concerns summary Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a failure in appreciating emerging patient risks.

Concerns summary The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow and comprehensive patient assessment within mental health teams.

Concerns summary Excessive ambulance delays of six hours forced family members to transport a distressed patient themselves, causing significant pain and discomfort.

Concerns summary A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them being passed between agencies without effective crisis intervention or multidisciplinary planning.

Concerns summary The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and skills in recognizing and responding to medical emergencies.

Concerns summary Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring patients under section, including required documentation.

Concerns summary Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of vulnerable individuals, and poor inter-agency information sharing. There was no single point of contact for complex cases and insufficient police training on domestic abuse and suicide risk.

Concerns summary The Root Cause Analysis for a patient's fall contained errors and failed to critically examine issues like call-bell functionality and specialist advice delays. The incident's "moderate" harm grading was not revisited despite its contribution to the patient's death.

Concerns summary A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.

Concerns summary A midwife delayed calling an ambulance despite meconium in a home birth, prioritizing other tasks, raising concerns about insufficient urgency in training. Additionally, the placenta was not retained, hindering vital examination for learning.

Concerns summary The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly patient. A 12-hour delay in ambulance arrival for a serious condition contributed to the patient's death, highlighting systemic risks.

Concerns summary The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also concerns about limited access to specialist pain clinics and underutilization of practice pharmacists for complex pain management.

Concerns summary Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly creating a risk to patient lives.

Concerns summary Ambulance service delays due to resource shortages caused rerouting and late arrival. The call algorithm failed to properly assess patient distress, and an unequipped private ambulance was dispatched due to miscategorization, leading to further delays.

Concerns summary A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.

Concerns summary Remedial works for dangerous trees at Sailors Creek were not undertaken despite obvious risks, directly contributing to a tragic death.

Concerns summary Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.

Concerns summary The A44 footpath crossing has limited visibility for both pedestrians and motorists, exacerbated by foliage, inadequate safety barriers, poor crossing design, traffic speed, and insufficient signage.

Concerns summary The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.

Concerns summary Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

Concerns On 1 stApril 2021 this Court commenced an investigation into the death of Elizabeth Margaret Mills age 71 years. The investigation concluded at the end of the inquest held on the 12 th November 2021...

Concerns summary Inadequate road drainage at a specific location causes dangerous surface water accumulation during heavy rainfall, leading to aquaplaning incidents that could be prevented by feasible improvements.