2024

Concerns summary National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics unit, as per London Ambulance Service practice.

Concerns summary GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the lack of a formal policy for referral thresholds risks missed cancer diagnoses.

Concerns summary It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.

Concerns summary The absence of advance warning signs for a layby situated at the bottom of a dip on a 50mph road created an unforeseen hazard, contributing to a fatal collision.

Concerns summary A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk assessment, and medication risks with alcohol were not communicated. Inconsistent recording of alcohol consumption and ignored family concerns compromised patient safety.

Concerns summary Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.

Concerns summary Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.

Concerns summary A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, especially during peak demand.

Concerns summary Inadequate clinical notation by advanced nurse practitioners failed to sufficiently describe patient presentation, hindering appropriate escalation of care.

Concerns summary Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric units were identified. The absence of written agreements for minimum standards and communication protocols creates a significant risk of future deaths.

Concerns summary Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for pressure ulcers. Inadequate internal reviews and remote expert input further compromised timely intervention for a deteriorating patient.

Concerns summary The absence of a regulatory authority and mandatory inspections for "class BGD Luna 2 Paraglider" aircraft allowed unchecked self-repairs, leading to a fatal accident due to a propeller defect.

Concerns summary Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding a prisoner's anxiety and medication was missing, contributing to their death.

Concerns summary Paramedics lacked training in identifying a herald bleed and had no specific protocol to follow, despite its critical nature in specialist vascular knowledge.

Concerns summary A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.

Concerns summary National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also a lack of awareness regarding menopause as a factor in mental health deterioration.

Concerns summary An active website provides detailed instructions and direct purchasing links for substances to end one's life, posing a significant risk to vulnerable individuals.

Concerns summary Support workers providing 24-hour solo care to vulnerable clients lack mandatory certificated First Aid and Basic Life Support training, posing a significant risk of future deaths.

Concerns summary Government policies on lifeguard furlough and lack of advance notice for lockdown relaxation severely hampered RNLI's ability to staff beaches, contributing to drownings due to unpatrolled coastlines.

Concerns summary Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and ensuring safe ongoing care.

Concerns summary Persistent severe staffing shortages, bed unavailability, and long waiting lists for psychological treatment in mental health services resulted in inadequate patient screening and care coordination.

Concerns summary Clinicians risk missing treatable neurological conditions in elderly patients by attributing symptoms solely to old age instead of conducting thorough investigations.

Concerns summary Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell usage ability, hindering emergency alerts.

Concerns summary The confusing design of a road junction, featuring conflicting traffic lights and inadequate pedestrian signals, creates a significant and unclear crossing risk for pedestrians.

Concerns summary Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care for a hard-of-hearing patient.