2023

Concerns summary An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.

Concerns summary Bath seats create a false sense of security for parents, despite not being safety devices. There is a concerning lack of national advice to healthcare professionals and parents regarding their safe use.

Concerns summary National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing their risk of harm.

Concerns summary Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also delayed crucial organizational learning.

Concerns summary Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a patient with Addison's disease after trauma. Trust guidelines and documentation lacked crucial prompts for adrenal insufficiency.

Concerns summary Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received no medical review for four days, indicating a severe failure in monitoring and timely clinical intervention.

Concerns summary Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical priority. Delays in incident reporting and family communication were also noted.

Concerns summary The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant safety risk for broken-down vehicles.

Concerns summary A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical lack of protocol for radiology report delivery.

Concerns summary Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.

Concerns summary A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient safety through delayed response times.

Concerns summary The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.

Concerns summary A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.

Concerns summary There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care frameworks, leading to fragmented support and increased risk during crises.

Concerns summary Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific alcohol misuse guidance from the Rugby Football Union for volunteer-run organizations.

Concerns summary The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of a scroll feature, and inability to prominently flag out-of-range values.

Concerns summary The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for persistent bleeding or medication effects, leading to dangerous treatment delays.

Concerns summary The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway safety risk that requires urgent attention and repair from National Highways.

Concerns summary The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.

Concerns summary Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding risks are prevalent.

Concerns summary Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.

Concerns summary An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and supervision to provide safe assistance.

Concerns summary The A690 junctions have a dangerous layout, high traffic volume, and inappropriate speed limits, with planned improvements being insufficient, untimely, and failing to address the series of junctions, risking further fatal collisions.

Concerns summary The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior clinician unilaterally overrode a Multi-Disciplinary Team decision, highlighting a lack of robust procedural oversight.