2023

Concerns summary Lack of clarity on NIV provision and failure to involve respiratory teams for patients with complex conditions, alongside inadequate monitoring and care continuity, led to missed patient deterioration.

Concerns summary Parents of a low birth weight infant were not provided essential SIDS prevention advice and documentation upon discharge, and the hospital failed to demonstrate that the underlying omission was corrected.

Concerns summary Confusion between multiple agencies regarding care terms, funding, and provision led to a mismatch between Matthew's expected and actual care, hindering proper support for his complex needs.

Concerns summary Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical deterioration in a patient's condition while awaiting transport.

Concerns summary An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating sepsis protocol, inadequate monitoring, and delayed senior review, which significantly contributed to the patient's deterioration.

Concerns summary The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training and staffing. Additionally, there is no standard referral form, risking missed vital information for supported housing placements.

Concerns summary Concerns include excessive freeplay in vehicle lifts, unsuitable lift pad adapters for narrow points, absence of critical safety warnings, and inadequate recall of lifts with substandard gear ring bolts.