2023

Concerns summary The falls risk assessment was completed inaccurately and not reassessed despite family warnings about compromised mobility. Furthermore, the Trust's internal investigation failed to identify these critical failures.

Concerns summary Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.

Concerns summary Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.

Concerns summary Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus stenting and associated perforation risks.

Concerns summary GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information sharing. The effectiveness of new training and tools remains unconfirmed.

Concerns summary The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.

Concerns summary Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about wider patient safety.

Concerns summary Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.

Concerns summary High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of work.

Concerns summary Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, missing opportunities for earlier specialist assessment.

Concerns summary Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.

Concerns summary Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.

Concerns summary There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.

Concerns summary Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time limits or prioritization creates dangerous delays.

Concerns summary There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also deficient, excluding key stakeholders.

Concerns summary Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this potential risk with patients.

Concerns summary Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.

Concerns summary Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen testing for under 5s, creates diagnostic delays.

Concerns summary Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The emergency response was chaotic and staff records were found to be dishonest, indicating severe governance and care failures.

Concerns summary Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road incidents.

Concerns summary There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history in acute and mental health settings.

Concerns summary Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.

Concerns summary The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.

Concerns summary Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.

Concerns summary A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel perforation risk for diverticular disease patients.