2023

Concerns summary There are severe limitations in suitable specialist placements for young autistic adults with self-harm risks. Past unit closures have created a critical shortage of beds, leading to inappropriate care settings or discharge without adequate support.

Concerns summary The Hospital Overview was not updated promptly or correctly, and crucial discussions about patient repatriation to an available bed were not documented.

Concerns summary A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable infant deaths.

Concerns summary Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.

Concerns summary HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.

Concerns summary Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.

Concerns summary The hospital's policy regarding the out-of-hours availability of Resuscitation Officers requires review to ensure timely emergency response.

Concerns summary Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a pilot in distress.

Concerns summary Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.

Concerns summary Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.

Concerns summary Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.

Concerns summary Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.

Concerns summary Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.

Concerns summary The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.

Concerns summary Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from prior procedures.

Concerns summary Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous warnings, creating a significant risk of falls and fatal injuries.

Concerns summary A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.

Concerns summary Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, and local authorities continues to risk future deaths.

Concerns summary Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.

Concerns summary Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE policy, highlighting a need for review.

Concerns summary Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed assessment due to assumptions about substance misuse.

Concerns summary The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded by false reassurance from NEWS scores, led to missed opportunities for earlier treatment.

Concerns summary Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to increase awareness and mitigate this risk.

Concerns summary A high-risk falls patient was inadequately protected by only one sensor mat. Furthermore, the incident investigation was unrecorded, and involved staff could not be identified.

Concerns summary Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.