2024

Concerns summary A lack of systematic allergy awareness, regular patient reviews, and proper management structures for anaphylaxis risk leaves diagnosed individuals vulnerable to future deaths.

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.

Concerns summary Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff turnover, which poses a risk to patient safety.

Concerns summary The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address deep, fast-flowing water dangers and implement identified safety works.

Concerns summary Long-distance service buses traveling at high speeds on rural routes are exempt from seatbelt requirements, posing an unacceptable risk of death or injury to passengers in collisions.

Concerns summary Travelodge hotels lack 24-hour availability of fully trained first aid staff, and all employees lack comprehensive basic first aid training, posing a risk during emergencies.

Concerns summary The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.

Concerns summary The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.

Concerns summary Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.

Concerns summary The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.

Concerns summary Inadequate barriers and signage on the promenade fail to protect mobility scooter users from variable, significant drop-offs, especially if they fall asleep, risking falls onto the beach.

Concerns summary The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading to the irretrievable loss of critical, time-sensitive evidence.

Concerns summary The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap in pastoral support and risk of overlooking struggling individuals.

Concerns summary Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side effects of excess vitamin supplements.

Concerns summary Clear guidelines are needed to ensure acute trusts refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, as clinicians were unaware of existing protocols.

Concerns summary There were concerning delays in the London Fire Brigade's response, specifically in deploying an extended height ladder appliance, to a person on a block of flats roof.

Concerns summary Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.

Concerns summary Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.

Concerns summary The provided concerns text was incomplete, preventing a meaningful summary of safety issues.

Concerns summary The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded by a lack of staff training.

Concerns summary Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely delivery of urgent, centralised cardiac care.

Concerns summary Ineffective communication, incomplete documentation, and unclear policies for medication management, VTE prophylaxis, and discharge safety led to gaps in patient care and potential risks.

Concerns summary Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the patient's carer.

Concerns summary The hospital's inability to provide immediate paediatric x-rays and chest ultrasounds outside of limited hours poses a significant risk to children with deteriorating pneumonia or suspected pleural effusions.

Concerns summary Inadequate welfare check procedures, inconsistent recording, an unreliable IT system, and missed opportunities to assess a vulnerable resident led to a significant delay in discovering their condition.