2023

Concerns summary Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.

Concerns summary Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was no investigation into the operating table death, and embalming and medical reporting were inadequate.

Concerns summary Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically high levels and warranting review.

Concerns summary Emergency department pressures at OPEL 4 led to extensive triage delays and patient deaths, compounded by GPs not providing a realistic picture of waiting times.

Concerns summary Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited staff awareness of ligature risks compromised patient safety.

Concerns summary The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests led to a missed diabetes diagnosis.

Concerns summary The provided text details investigations into the criminal case and welfare support for the deceased but does not specify the particular safety issues or systemic failures identified.

Concerns summary Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation decision overlooked wider health problems.

Concerns summary Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing demand.

Concerns summary A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to be sold and mixed, causing fires, thermal runaway, and multiple deaths.

Concerns summary The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.

Concerns summary Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, raising concerns about easy access for individuals intending self-harm.

Concerns summary Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a pilot in distress.

Concerns summary Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders in such environments.

Concerns summary Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient care.

Concerns summary Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies being sold to the public.

Concerns summary Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to preventable deaths.

Concerns summary Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable tenant without effective assistance.

Concerns summary Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in a child's fatal overdose.

Concerns summary Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.

Concerns summary The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue driving.

Concerns summary Unreliable and difficult-to-use home SATS machines, coupled with inadequate parent training on specific models, created a false sense of security and failed to alert parents to critical oxygen drops.

Concerns summary Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared with the occupational therapy department, created significant safety gaps.

Concerns summary The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and future deaths.