2023

Concerns summary A lack of clear guidance for prescribing intravenous Acyclovir, instead of ineffective oral medication, potentially led to incorrect treatment and preventable death for the patient.

Concerns summary A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.

Concerns summary A nationwide shortage of care providers and carers prevents commissioned care packages from being fulfilled, risking individuals not receiving necessary care with potentially fatal results.

Concerns summary Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.

Concerns summary Known highway defects, including surface water and flooding, were not remedied by the local authority, posing a clear risk of future fatal road incidents.

Concerns summary Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.

Concerns summary Custody sergeants lacked understanding of Liaison and Diversion team processes, available information, and how to complete pre-release risk assessments. This indicates a training need for recognizing vulnerability at discharge.

Concerns summary GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.

Concerns summary Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or clear channels for raising concerns. Local authority support also lacks formal policy.

Concerns summary Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a family from seeking assistance during a crisis.

Concerns summary Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.

Concerns summary Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.

Concerns summary Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.

Concerns summary The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive treatment based on their home address and time of stroke.

Concerns summary Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.

Concerns summary A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.

Concerns summary A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.

Concerns summary Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.

Concerns summary Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was not a formal system, risking future harm.

Concerns summary A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.

Concerns summary A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to an ill-timed operation.

Concerns summary Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.

Concerns summary Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.

Concerns summary A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.

Concerns summary A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.