2023

Concerns summary A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.

Concerns summary Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.

Concerns summary Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they pose to young children.

Concerns summary Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.

Concerns summary The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.

Concerns summary Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.

Concerns summary Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.

Concerns summary The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a rapid access chest pain clinic.

Concerns summary There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately involve or inform the patient's family about his mental health.

Concerns summary A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.

Concerns summary The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting of self-harm risks, poses a significant risk of future deaths.

Concerns summary A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing between authorities also failed to recognize a safeguarding risk, endangering residents and staff.

Concerns summary Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and impeding crucial treatment for patients with severe conditions.

Concerns summary Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.

Concerns summary Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a critically delayed radiological report.

Concerns summary Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout their inpatient stay.

Concerns summary Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to inaccessible communication, and inadequate assessment of participant swimming ability or fitness.

Concerns summary A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic social care shortages.

Concerns summary There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to his death.

Concerns summary The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.

Concerns summary School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation processes and poor communication between the school and external providers.

Concerns summary Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.

Concerns summary Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.

Concerns summary UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea swimming and snorkelling in unfamiliar locations with strong currents.

Concerns summary Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of eating disorders, risking unaddressed, urgent medical needs for vulnerable service users.