Care plan failures
166 items
2 sources
Care plans not accurately reflecting individual needs or care provided, and ineffective systems for quality assurance and continuous improvement.
Cross-Source Insight
Care plan failures has been flagged across 2 independent accountability sources:
28 inquiry recs
138 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (28)
IBI-10a(iv) — Thalassaemia Society Support
Recommendation: Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
Gov response: UK Government NHS England has successfully established a comprehensive programme of work to prioritise reduction of clinical risk, increase support and care in the community, digitise care plans and step up prevention activities following their …
Accepted in Part
In progress
IBI-2c — Community Support Events
Recommendation: There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
In progress
IBI-9d — Haemophilia Centre Resources
Recommendation: The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they …
Gov response: UK Government Recommendation 9d: The need to develop and strengthen multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders to improve patient care and support standardisation is supported by …
Accepted
In progress
F236 — Identification of who is responsible for the patient
Recommendation: Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who is in overall charge of a patient's care.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
WATE-(12) — Safeguard field social worker's responsibilities for placement supervision and care planning
Recommendation: Any arrangements made for the provision of residential care or fostering services should expressly safeguard the field social worker's continuing responsibilities for supervision of the placement and care planning.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(34) — Designate social worker responsible for care plan implementation and child supervision
Recommendation: An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Unknown
WATE-(35) — Ensure foster carers receive continuing support and access to specialist services
Recommendation: Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us"919.
Unknown
WATE-(36) — Provide facilities and encourage acquisition of independent living skills in care settings
Recommendation: The daily regime in residential establishments and foster homes should encourage and provide facilities for the acquisition of skills necessary for independent living.
Unknown
WATE-(37) — Prepare and periodically review leaving care plans for all looked after children
Recommendation: A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for …
Unknown
WATE-(38) — Extend local authority duty to provide parental-level support for care leavers
Recommendation: The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so …
Unknown
WATE-(39) — Require fostering services to monitor, analyse, and report placement breakdowns periodically
Recommendation: Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director …
Unknown
WATE-(40) — Develop key indicators to monitor compliance with safeguards for looked after children
Recommendation: Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:34, 62(i) (a) the allocation of a designated social worker to each looked after child; (b) compliance with fostering and placement regulations; (c) statutory review …
Unknown
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
COVID-M3.9 — Standardised Advance Care Planning
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for …
Gov response: No formal response published by this government.
Unknown
R18 — Care planning system
Recommendation: Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
Gov response: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear and accurate records. This includes identifying any risks or problems and …
Accepted
R22 — Relative discussions recorded
Recommendation: Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, effective from March 2015, requires nurses and midwives to complete clear and accurate records at the time …
Accepted
R24 — TVN instructions recorded
Recommendation: Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, requires clear and accurate records to be maintained, completed at the time of …
Accepted
R26 — Wound documentation
Recommendation: Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code requires nurses to maintain clear and accurate records, completing them as soon as possible after an event …
Accepted
R27 — Positional change records
Recommendation: Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
Accepted
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's criticisms of specific elements of nursing care, including the unsatisfactory assessment and recording of patients' nutritional status. The government unreservedly accepts in full the report's …
Accepted
R30 — Fluid balance monitoring
Recommendation: Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts as accurately as possible.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
Accepted
R39 — DNAR decision awareness
Recommendation: Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
Gov response: Section 4.1 of the Scottish Government's response notes that recommendation 39 focuses on the clinically and ethically challenging aspects of Do Not Attempt Cardiopulmonary Resuscitation (DNAR) orders. The report sets out precise standards for decision-making, …
Accepted
LAMI-64 — Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Unknown
PFD Reports (138) — showing 100 most recent
Ronald Nelson
Concerns: Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.
Overdue
Ramona Harbott
Concerns: Care home staff failed to adhere to pressure sore prevention policies, leading to inadequate repositioning, poor skin monitoring, and severe, undocumented pressure sores for a high-risk patient.
Response: Barchester Healthcare has engaged a Clinical Development Nurse to provide weekly training on wound care and pressure ulcer prevention at Windmill Manor Care Home. They have also commenced implementing an …
Overdue
June Findlay
Concerns: Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify these consistent failures.
Response: Frimley Health NHS Foundation Trust has implemented a new Nutritional & Hydration Audit tool, developed and launched a new care planning tool with supporting guidance, and produced a training programme …
Responded
Richard Worswick
Concerns: Unclear wound care instructions on hospital discharge and a lack of documented communication between the hospital and care home led to confusion. The care home also lacked an escalation policy for such unclear care plans.
Response: Bamford Grange Care Home has issued refresher guidance on existing policies for re-admission and wound care monitoring, ensuring all calls to external teams are documented (including unsuccessful ones with mitigation …
Response: Stockport NHS Foundation Trust has issued a Trust-wide alert (20 November 2025) requiring two copies of Transfer of Care documentation to be printed: one for the patient and one for …
Responded
Evan Dandou-Dambelle
Concerns: Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
Response: The Trust has already communicated the learning to all consultant psychiatrists via email, emphasizing that significant medication changes must be considered when determining patient contact levels. This will be further …
Responded
Lynn Silcock
Concerns: A patient was discharged by gastroenterology without cardiology consultation or follow-up, due to a lack of communication and document exchange between teams, leading them to be "forgotten" and without trust investigation.
Response: NHS England states the specific issues raised fall outside its direct role and remit, primarily resting with Shrewsbury and Telford Hospital NHS Trust (SATH). It notes its existing national Frontline …
Response: The Trust has initiated a Patient Safety Investigation (PSII), completed a review of discharge processes in Gastroenterology with Cardiology input, and created a new policy for referrals. A single referral …
Responded
Steven Turzynski
Concerns: Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Response: Velindre University NHS Trust has undertaken a comprehensive review, implementing improvements to nutritional assessment, strengthening communication, and introducing guidelines for dietetic assessments and face-to-face consultations. A draft Standard Operating Procedure …
Response: Aneurin Bevan University Health Board has implemented a strengthened governance framework for nutrition and hydration, including a Strategic Nutrition and Hydration Group. They are also developing a joint Standard Operating …
Responded
Margaret Taylor
Concerns: A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.
Responded
Maureen Powell
Concerns: Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.
Responded
Esther Byrne
Concerns: Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.
Responded
Raihana Oluwadamilola Awolaja
Concerns: A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.
Responded
Patricia Catterall
Concerns: The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Responded
Derrick Tully
Concerns: Failures included unsuitable housing without a key safe, an inappropriate reablement package for a cognitively impaired patient, and neglected recording/escalation of patient deterioration, leading to missed care needs.
Responded
Cynthia Gilbert
Concerns: Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and the efficacy of post-death investigations.
Responded
Edith Pye
Concerns: The care home had ambiguous care plans, staff routinely failed to follow safety protocols, and handover documents were deficient and unaudited, indicating systemic failures in ensuring resident safety.
Responded
Gloria Linton
Concerns: 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.
Responded
Ian Hegarty
Concerns: A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical risk has been addressed.
Responded
Sylvia Prichard
Concerns: The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.
Responded
James Astley
Concerns: Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.
Responded
Mavis Dewey
Concerns: Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.
Responded
Alfred Sparrow
Concerns: Care home staff failed to provide necessary assistance with food and fluid intake and made false care note entries, indicating a systemic failure that jeopardises resident safety.
Responded
Owen Gardner
Concerns: A patient with cognitive deficit missed appointments because his next of kin were not consistently informed of schedules or short-notice changes, risking future adverse health outcomes.
Responded
Norman Leadbeater
Concerns: Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs remain incomplete months after recommendation.
Responded
Ash Bannister
Concerns: Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.
Responded
Darnell Smith
Concerns: A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.
Responded
John MacGregor
Concerns: Concerns exist regarding the poor quality and completion of residents' care documentation and inadequate procedures for escalating or not escalating care following a fall.
Responded
Daniel Tucker
Concerns: Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.
Responded
Nadia Wyatt
Concerns: 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.
Responded
Iris Fordham
Concerns: Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.
Responded
Geoffrey Brooks
Concerns: An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to the patient's critical dehydration and contributing to his death.
Responded
Terence Burns
Concerns: A patient's care plan failed to accurately document their essential blended diet, and critical nutritional information was not checked or transferred during hospital admission, risking appropriate care.
Responded
George Griffiths
Concerns: A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.
Responded
Julie Nolan
Concerns: Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.
Responded
Lugh Baker
Concerns: The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.
Responded
Bridget Gormley
Concerns: Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of increased risk and implementation of critical mitigation measures.
Overdue
Sophia Ayuk
Concerns: The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring food and fluid intake were inadequately followed during her inpatient care.
Overdue
Anthony Blower
Concerns: Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's hydration policy, leading to patient dehydration without clear accountability.
Overdue
Tracy Brown
Concerns: Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to instruct carers to secure the medication, posing a safety risk.
Responded
Janice Hopper
Concerns: The care plan was inaccurate, not person-specific, and vital medical monitoring—including weight, blood sugar, and fluid intake—was neglected or poorly recorded. Additionally, medication was administered inappropriately and care plans lacked regular review or audit.
Responded
Ann Daghlian
Concerns: The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to monitor whether care plans were being met, despite clear signs of refusal for essential care.
Responded
Robert Howell
Concerns: Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a lack of understanding of resident needs and falls policies.
Responded
Lilian Shearing
Concerns: Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.
Responded
Susan Regan
Concerns: The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown in properly recording and communicating the care plan with the family.
Responded
Gerald Tuck
Concerns: The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to a crucial falls risk assessment not being updated after multiple falls, increasing future risk.
Responded
Lily Girton
Concerns: Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Overdue
Stanislav Mucha
Concerns: There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure to progress critical steps like a warrant, delaying further intervention.
Responded
Beryl Simcock
Concerns: The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.
Responded
Natasha Adams
Concerns: A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.
Responded
Norman Barnes
Concerns: Care home staff were unaware of crucial dietary requirements and other key information in resident care plans and risk assessments, leading to inadequate and potentially unsafe care delivery.
Overdue
Reginald Weston
Concerns: The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Responded
Robert Hammond
Concerns: The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.
Responded
Neil Bastock
Concerns: The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's specific concerns regarding systemic failures or risks.
Responded
Alan Hunter
Concerns: Poor documentation, incorrect BMI calculation, and failure to follow NICE guidance on weight monitoring led to an inaccurate assessment of the patient's nutritional risk and status.
Responded
Uyapo Theodore Hayunga-Macha
Concerns: A mentally unwell patient left the emergency department unattended while awaiting triage, raising concerns about inadequate supervision and leaving vulnerable individuals unwatched during assessment.
Responded
Eldine Lashley
Concerns: The patient's mobility care plan was not updated to reflect increased observation needs, and staff progress notes inaccurately recorded the frequency of checks performed.
Overdue
Dorothy Seekings
Concerns: Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Responded
Richard Burgess
Concerns: Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred policies effectively.
Responded
Stephen Thurm
Concerns: Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs were also not integrated into long-term plans.
Responded
Anthony Wilkinson
Concerns: The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.
Responded
Shirley Froggett
Concerns: New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Overdue
Margaret Greenacre
Concerns: The care home failed to promptly report safeguarding incidents to the CQC, with notifications significantly delayed or entirely missed. Record-keeping was very poor, hindering staff's understanding of resident needs.
Responded
Lisa Thompson
Concerns: Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.
Responded
Norma Lockton
Concerns: The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating medical condition (cellulitis), leading to delayed medical assistance and an inadequate post-death review.
Overdue
Claire Lilley
Concerns: Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Responded
Kimberley Smith
Concerns: The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Responded
Sean Owen
Concerns: Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.
Responded
John Gregory
Concerns: Inadequate staff standards, inconsistent encouragement of fluid intake, and failure to monitor and respond to a patient's deteriorating condition, including inaccurate record-keeping, contributed to significant neglect.
Overdue
Lewys Crawford
Concerns: A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.
Overdue
Wayne Millett
Concerns: The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review medication side-effect monitoring protocols.
Responded
Adam Bojelian
Concerns: The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, leading to disputed treatment.
Overdue
Keith Whetton
Concerns: The care home failed to seek prompt medical attention after a resident's fall and did not inform family members in a timely manner.
Responded
Sidney Baker
Concerns: Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.
Responded
Dorothy Macey
Concerns: Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.
Overdue
Emily Sims
Concerns: Care plans were not updated to reflect changing needs or multidisciplinary decisions. There was a lack of appropriate equipment, specialist advice, and staff training in equipment use and moving/handling.
Responded
Barbara Humphreys
Concerns: Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There was also a failure to inform families of medically relevant events.
Overdue
Keith Heatley
Concerns: There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Responded
John Delahaye
Concerns: National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Overdue
Veronica Gregory
Concerns: Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.
Responded
Sylvia Davies
Concerns: Virgin Care's delay in adopting new urgent care assessment standards and the failure to transcribe or retain crucial patient information provided by families create ongoing safety risks.
Overdue
Stanley Langdon
Concerns: A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Overdue
Patricia Heslop
Concerns: Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.
Responded
Ellie Clark
Concerns: Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable to challenge decisions, impacting patient safety.
Overdue
Francis Beech
Concerns: The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to implement cast care plans, monitor for infection, or train staff.
Overdue
Irene Baker
Concerns: The care home failed to revise mobility care plans despite documented deterioration and missed monthly reviews. They also failed to escalate concerns, like inability to weight-bear, to a GP or emergency services.
Responded
Mildred Griffiths
Concerns: The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.
Responded
David Jackson
Concerns: Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks in community health care for vulnerable individuals.
Overdue
June Evans
Concerns: Agency staff unfamiliarity led to unreferred pressure sores, clinicians were unaware of patient deterioration, nutritional advice was ignored, and understaffing compromised care.
Overdue
Bernard Cosgrove
Concerns: Hospital staff failed to recognise a patient's dislocated hip for 7 days, despite clinical record entries and physical handling. This highlights insufficient patient monitoring and inadequate consideration of previous medical records before discharge.
Responded
Christopher Roberts
Concerns: Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.
Overdue
Sofia Legg
Concerns: Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.
Responded
Helen Bannister
Concerns: Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.
Overdue
Janet Williams
Concerns: The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.
Overdue
James Harris
Concerns: Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Responded
Cameron Chadwick
Concerns: A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.
Responded
Rose Workman
Concerns: The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.
Responded
John Ramsden
Concerns: Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Overdue
Patricia Norfolk
Concerns: Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.
Overdue
Sheila Hynes
Concerns: A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Overdue
Robert Cardwell
Concerns: Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Overdue
Constance Connolly
Concerns: Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical diagnostic investigations.
Responded