2023

Concerns summary The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to a critical misassessment of suicide risk and an inadequate care plan.

Concerns summary An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.

Concerns summary Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured risk management tools. British Transport Police's multi-agency support plan also failed to communicate railway station attendances, especially from unstaffed stations.

Concerns summary Severe staff shortages in the care home led to reduced contact time and checks for a vulnerable resident, contributing to an accidental fall and subsequent fatal complications from surgical treatment.

Concerns summary GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.

Concerns summary The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive treatment based on their home address and time of stroke.

Concerns summary A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.

Concerns summary Inadequate CCTV coverage beyond station platforms and failure to immediately transmit footage to Route Control rooms increase the risk of undetected incidents in busy stations.

Concerns summary The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.

Concerns summary The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.

Concerns summary A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about this known drug interaction, leading to dangerously high INR levels.

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 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 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 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 Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for hazards, and failing to provide lifejackets.

Concerns summary A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.

Concerns summary Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.

Concerns summary There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for vulnerable individuals.

Concerns summary Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to fatal delays.

Concerns summary The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.

Concerns summary The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early mobilisation and increasing patients' risk of complications like pneumonia.

Concerns summary Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for biliary sepsis collectively increased mortality risk.

Concerns summary Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not readily available and a promised service is unimplemented.