2022

Concerns summary Busy Emergency Departments and ambulance offload delays postpone critical x-rays. Additionally, there is no clear escalation process to ensure x-rays are completed when overlooked by staff, risking missed diagnoses.

Concerns summary A signals controller failed to advise trains to proceed with caution, indicating a critical lapse in railway safety protocol.

Concerns summary The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.

Concerns summary The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.

Concerns summary University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS liaison, and adequate systems to ensure student safety after distress.

Concerns summary A busy road junction has dangerously obscured vision for exiting vehicles due to its layout, bend, and foliage, exacerbated by a 50mph speed limit on the main road, risking collisions.

Concerns summary Medical professionals lacked sufficient training and awareness regarding the rare but critical risk of sepsis following Early Medical Terminations, leading to significant delays in diagnosis and treatment.

Concerns summary Improper food preparation, unassessed feeding techniques, and inadequate staff training in choking first aid and CPR led to unsafe feeding practices and a failure to recognise and respond to cardiac arrest.

Concerns summary Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.

Concerns summary Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of future vehicle collisions and potential loss of life.

Concerns summary The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.

Concerns summary The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.

Concerns summary Unmaintained electrical equipment during the COVID-19 pandemic increased fire risks, exacerbated by a failure to reassess these dangers and a lack of contingency planning for future lockdown scenarios.

Concerns summary Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.

Concerns summary While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary care.

Concerns summary National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.

Concerns summary A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.

Concerns summary Ambulance crew lacked awareness that seizures combined with cocaine were a medical emergency, resulting in delayed blue-light transport and appropriate treatment due to misjudged urgency.

Concerns summary Fire safety failures included incompetent staff, non-compliant fire alarms without automatic emergency service links, unfit policies, flawed audits, and dangerous keypad locks on exit doors.

Concerns summary Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.

Concerns summary Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.

Concerns summary Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration concerns.

Concerns summary Insufficient information regarding unusual methods of fentanyl misuse poses a significant risk of future deaths due to its potential for varied abuse.

Concerns summary Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.

Concerns summary Persistent paramedic response delays are caused by ambulance staff and vehicle shortages, compounded by A&E department pressures preventing timely ambulance clearance.