2024

Concerns summary Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting patient safety.

Concerns summary A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.

Concerns summary Police failed to adequately assess a vulnerable individual, relying on minimal interaction and flawed assumptions about drug use. There was also a lack of follow-up checks and no demonstrable learning or procedural changes post-incident.

Concerns summary Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a significant overdose risk.

Concerns summary There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug treatment teams hindered safe discharge planning.

Concerns summary Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding procedures, and ineffective challenge processes between mental health services and police.

Concerns summary Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were concerns. There were also unaddressed issues with medication ordering and insufficient training for agency staff.

Concerns summary Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and posed a safety risk.

Concerns summary Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible across different sites.

Concerns summary A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.

Concerns summary Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care investigations, failing to assess the mental health impact of child removal processes or provide independent support. Funding for specialist therapy was also problematic.

Concerns summary A national shortage of District Nurses resulted in significant delays for patients needing urgent care, preventing timely assessment and treatment according to their health needs.

Concerns summary High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.

Concerns summary There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, leading to inconsistent policies and practical instructions for staff.

Concerns summary A national radiologist shortage leads to delayed X-ray reporting, risking missed fractures and diverting ED consultant resources. Additionally, community and primary care teams lack training to identify critical deterioration in fracture patients.

Concerns summary Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals released at short notice.

Concerns summary Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates potentially critical treatment delays.

Concerns summary Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving a significant learning gap.

Concerns summary Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent with expected standards and poses a risk.

Concerns summary Early Years Foundation Stage rules allow only one Paediatric First Aid certified staff member, risking inadequate emergency response. Additionally, the three-year PFA certificate validity means staff may not recall critical details in emergencies.

Concerns summary Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.

Concerns summary Unmanaged risk of flooding and standing water on a specific road stretch has led to multiple incidents of vehicles losing control, posing a continued risk of future deaths.

Concerns summary Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.

Concerns summary A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to wait in A&E.

Concerns summary An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.