2023

Concerns summary Paramedics failed to correctly interpret an abnormal ECG and lacked fundamental knowledge of key indicators, despite auto-diagnostic warnings. Inadequate qualitative training assessment and lack of post-incident training pose a significant patient safety risk.

Concerns summary Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.

Concerns summary Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose a critical risk to patient safety.

Concerns summary The absence of a national policy for Central Venous Catheter (CVC) placement leads to inconsistent and potentially unsafe practices across hospitals. A standardised national policy is needed to ensure patient safety.

Concerns summary A vulnerable adult's safeguarding concerns were disregarded at triage, and a recommended care assessment was overridden. Systemic failures in referral processing and case management risk vulnerable individuals being overlooked.

Concerns summary Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not perform consistent welfare checks. Inadequate self-harm training and a chaotic culture contributed to missed opportunities for intervention.

Concerns summary Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were hidden, had insufficient rope length for low tide, and were inadequate in number.

Concerns summary Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to access NHS notes, creating information deficits that compromise risk assessments and care plans.

Concerns summary Street lighting was unlit due to an underground cabling fault, likely from a previous collision. This lack of illumination along the road created a dangerous hazard for road users.

Concerns summary Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights a missed opportunity for potentially life-saving intervention in opiate overdose cases.

Concerns summary The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.

Concerns summary Planned reductions in paediatric specialist training time in Level 3 Neonatal units risk future middle-grade and consultant general paediatricians having inadequate practical experience in neonatal resuscitation.

Concerns summary Persistent and significant ambulance non-availability in the East of England region led to extreme delays, where prompt arrival and early treatment could have saved a patient's life.

Concerns summary The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering effective assessment. A critical updated risk chart (NEWTT2) remains unimplemented despite being overdue.

Concerns summary A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by the single point of access system.

Concerns summary Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual daily contact.

Concerns summary Persistent and severe ambulance non-availability in the East of England led to nearly 10-hour delays. Expert evidence indicates that prompt ambulance arrival and early treatment could have saved the patient's life.

Concerns summary DWP procedures, including lengthy forms, long phone queues, and travel requirements, are impractical and exacerbate symptoms for individuals with mental health illnesses.

Concerns summary The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack of required protective equipment could lead to future deaths.

Concerns summary St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin inspections, and incident reporting. This indicates systemic governance and quality assurance deficiencies.

Concerns summary A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls highlighting their deteriorating condition.

Concerns summary There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to community care, leading to potential gaps where high-risk patients' needs are not met.

Concerns summary The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.

Concerns summary The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in record-keeping and communication.

Concerns summary Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.