2024

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 Current regulations are outdated, posing significant public road safety risks.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 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 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 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.

Concerns summary The absence of mandatory medical checks for drivers over 70, who only self-declare fitness, poses a significant road safety risk. This enables drivers with declining abilities to remain on the road, contributing to fatal and serious collisions.

Concerns summary Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.

Concerns summary Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient monitoring protocols in the care home.

Concerns summary DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in a lack of clear communication and exacerbating the patient's paranoia about the money.

Concerns summary There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.

Concerns summary A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, or the wider industry.

Concerns summary Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.

Concerns summary The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led to significant delays in diagnosis and appropriate antibiotic treatment.

Concerns summary Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk management systems contribute to serious impact and vibration injuries. Licensing arrangements and interim safety measures are needed.

Concerns summary The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import and availability of substances used for poisoning, despite known risks.