2023

Concerns summary Excessive Emergency Department wait times due to staff shortages and lack of 'silver trauma' protocols for elderly patients delayed critical CT scans and transfer to trauma centers.

Concerns summary Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.

Concerns summary A significant road obstruction caused a fatal collision, highlighted by a lack of public awareness and legal obligation to report road hazards not directly caused.

Concerns summary Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.

Concerns summary Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff lacked mandatory refresher training.

Concerns summary Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.

Concerns summary Persistent excessive waits in A&E, often over 11 hours, are caused by high demand and a severe lack of hospital beds, delaying patient care and ward admissions.

Concerns summary There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.

Concerns summary Severe ambulance and Emergency Department delays, driven by high demand and staffing issues, led to prolonged waits and deterioration of frail, elderly patients.

Concerns summary Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.

Concerns summary Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.

Concerns summary Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.

Concerns summary The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.

Concerns summary Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied and new policies are not aligned with recording forms.

Concerns summary Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.

Concerns summary Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.

Concerns summary Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.

Concerns summary A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.

Concerns summary Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication and misunderstanding between the Trust and emergency services regarding escaped detained patients.

Concerns summary HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison staff. The Duty Governor also failed to make sufficient enquiries regarding health screens.

Concerns summary Significant delays in patient allocation and critical failures by the crisis team to reassess a depressed patient were compounded by an inadequate serious incident review and unclear team responsibilities.

Concerns summary Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc interventions not supported by policy.

Concerns summary Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.

Concerns summary Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.

Concerns summary Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy to prevent faulty decommissioned police vehicles from being sold, and a lack of national garage standards risks inadequate maintenance.