2023

Concerns summary A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, as no regulatory body assesses or requires thermostatic controls, unlike other health and social care settings.

Concerns summary Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. There was also staff confusion regarding responsibility for removing banned items on admission.

Concerns summary An individual clinician's reliance on memory instead of proper record-keeping creates a significant risk of information loss, potentially endangering future patients.

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 The absence of a barrier at the bottom of the weir, despite its hazardous re-circulating flow, particularly at high water levels, poses a significant risk of future drownings.

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 Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due to inadequate recognition and treatment of co-morbidities.

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 Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic areas, compounded by no national 'risk flagging' system or out-of-hours GP access.

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 A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along with no named accountability for allergy services, impedes understanding and prevention.

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 Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that earlier diagnosis and professional support could prevent deaths.

Concerns summary A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a lack of resilience and capacity in mental health services.

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 Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient public warnings regarding risks for users with cardiovascular/respiratory conditions.

Concerns summary The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous taxi operations, and insufficient traffic management for intoxicated crowds.

Concerns summary Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, contributed to missed opportunities for timely intervention and specialist referral.