2022

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 Mental health staff lacked critical knowledge and training on "Spice" dangers. Flawed Section 17 leave risk assessments meant escorts were unaware of recent drug-related risks or patient care plans, compromising safety.

Concerns summary Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.

Concerns summary Multiple failures included delayed specialist consultation for a dermatological emergency, unacted-upon critical blood results, and severe delays in A&E and ward care. Covid restrictions also hindered family advocacy.

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 Unregulated Ayurvedic practice resulted in a practitioner failing to recognize severe drug-induced liver injury and advise immediate remedy cessation. The GP also failed to adequately investigate or act on concerning symptoms.

Concerns summary Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, including the higher suicide prevalence for autistic individuals. Staff lacked understanding of specialist team access.

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 Critical deterioration and pain were not escalated to appropriate healthcare professionals, and comprehensive care plans, including for pressure areas and falls, were absent. Staff training and escalation procedures for deteriorating patients were inadequate, leading to undocumented pressure ulcers.

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 There was a significant lack of collaborative working and information sharing between healthcare agencies during discharge, resulting in a patient with complex needs being sent to unsuitable accommodation against clinical recommendations.

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 A GP failed to read a critical alert in patient records regarding an infection risk, and the subsequent investigation into this incident was inadequate, lacked proper format, and was not disclosed.

Concerns summary The care home lacked a documented system to restrict access to harmful items for at-risk residents and staff training on isolation's impact. Crucially, there were significant failures in transferring vital suicide risk information between agencies during patient handover.

Concerns summary There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.

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.