2023

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 The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of early death due to delayed intervention.

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 A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed access to services, and lack of proactive support. Staffing shortages and poor family engagement further jeopardized care.

Concerns summary A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.

Concerns summary Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and interaction. Delays in emergency service response further leave staff unequipped to handle vulnerable people for extended periods.

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 A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying and escalating health and safety issues.

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 Clinically trained nursing home staff failed to assess DVT risk for an immobile patient, did not obtain preventative measures like TED stockings, and inadequately mobilized her post-discharge.

Concerns summary An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe missed response target highlights a risk of future deaths from prolonged lying and related injuries.

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 Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.

Concerns summary Southmead Hospital had serious patient safety deficiencies. Concerns remain regarding the adequacy of current staff training and the measures in place for ongoing training of new staff.