2024

Concerns summary Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.

Concerns summary Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.

Concerns summary Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment for an aortic dissection, contributing to the patient's death.

Concerns summary A newly qualified midwife was distracted by administrative tasks, missing critical CTG changes. The obstetric registrar failed to identify acute hypoxic injury due to reliance on historic data, and senior staff delayed emergency response despite prolonged abnormal CTG.

Concerns summary Carers repeatedly failed to use a mandated transfer aid (Rotanda), contravening the care plan and previous instructions. This non-compliance resulted in improper patient positioning and injury.

Concerns summary Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a different team and not returning to the operating hospital for essential follow-up.

Concerns summary The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information sharing and documentation between medical and command personnel further hinder support and risk reduction.

Concerns summary A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.

Concerns summary Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.

Concerns summary Community care lacks a formal structure for physiological observations, relying on subjective clinician judgment, and trained staff may not effectively identify deterioration. A critical training program and policy for preventing untrained bank staff from working are significantly delayed.

Concerns summary A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.

Concerns summary A vulnerable patient was left without an accessible call bell, and care staff lack a checklist to ensure essential safety aids are consistently in place for residents.

Concerns summary Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are outdated, posing significant public road safety risks.

Concerns summary The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.

Concerns summary Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when vehicles leave the road. Their placement also obstructs pedestrian safety.

Concerns summary Poor phone line quality and unclear communication from nursing staff hindered emergency calls. Additionally, a faulty resident call bell meant staff couldn't reliably be alerted, posing a significant safety risk.

Concerns summary Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.

Concerns summary A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.

Concerns summary Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.

Concerns summary Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.

Concerns summary A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.

Concerns summary Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing a risk to life. Crucial items were also prematurely removed from the fire scene, hindering investigation into the cause.

Concerns summary The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.

Concerns summary A vulnerable young adult illicitly obtained an animal-licensed substance for suicide, highlighting an emerging risk. Licensing bodies and veterinary societies must examine preventive measures to curb access and prevent future deaths.

Concerns summary Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for specific requests. This issue, not fully addressed in an After Action Report, risks future diagnostic errors.