2023

Concerns summary Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures and oversight.

Concerns summary Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient patient repositioning.

Concerns summary Delayed hospital discharge for frail elderly patients, caused by insufficient social care provision, leads to deconditioning and increased risk of infection and preventable death.

Concerns summary Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that hinder effective falls prevention.

Concerns summary Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient safety risks.

Concerns summary Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.

Concerns summary Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.

Concerns summary Inadequate and inconsistent information provided to expectant mothers regarding sensitising events and when to call maternity triage increases the risk of Rhesus disease in newborn babies.

Concerns summary Severe, common delays in emergency department clinician assessments, exacerbated by radiography shortages, led to significant patient deterioration and missed opportunities for timely treatment.

Concerns summary Sustained pressure on emergency services caused significant delays in ambulance response and hospital processing for an elderly frail patient, increasing their risk of death after a fall.

Concerns summary Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.

Concerns summary Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.

Concerns summary Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.

Concerns summary Elderly, frail patients with hip fractures faced prolonged ambulance waits and significant delays in Emergency Department and ward transfers, posing a high risk to their health.

Concerns summary Systemic demand and patient flow issues led to prolonged ambulance waits and emergency department delays, preventing timely pressure ulcer prevention and increasing risks for frail patients.

Concerns summary Ambulance service delays, caused by high demand and slow hospital offloading, led to dangerously long wait times for frail, elderly patients with serious injuries like hip fractures.

Concerns summary The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.

Concerns summary Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.

Concerns summary Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.

Concerns summary Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.

Concerns summary Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.

Concerns summary A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.

Concerns summary Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.

Concerns summary Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.

Concerns summary The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, leading to a risk of other unassessed modified vessels operating unsafely.