Significant event log failures
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
120 items
10 sources
8 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
88match
Billet Lane Medical Practice
Takeactiontorecordthereviewsofsignificanteventsatclinicalmeetingsandcompleteasignificanteventlog.
Matched on
terms: event, log, significant
Inquiry recommendation
70match
MAI-84 - Review NWFC incident log information storage
North West Fire Control should review the way it captures and records key information on its incident logs in order to ensure that the information is stored in one place and is readily accessible at all times by those who need it
Matched on
terms: log
PFD report
69match
Chloe Every
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Matched on
terms: failure
CQC action
67match
The Peter Gidney Neurodisability Centre
The home was not notifying CQC or the funding authorities of significant events.
Matched on
terms: event, significant
CQC action
67match
Ashbourne House - Torquay
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.
Matched on
terms: event, significant
Inquiry recommendation
65match
COVID-M1.4 - UK-wide Civil Emergency Strategy
The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. The strategy should: be adaptable; include sections dedicated to each potential whole-system civil emergency; consider a wide range of potential scenarios for each type of emergency; identify...
Matched on
terms: event, log
PFD report
61match
Thomas Burchell
Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.
Matched on
terms: event
PFD report
61match
Matthew Gunn
An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
Matched on
terms: event
PFD report
61match
Eileen Pollard
Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Matched on
terms: failure
CQC action
60match
Bousfield Surgery
Improve the management of significant events and complaints by providing appropriate training to the person responsible for the investigation and documentation of significant events and complaints.
Matched on
terms: event, significant
PFD report
57match
Janet Hall
The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend analysis.
Matched on
terms: event
Inquiry recommendation
57match
F98 - National Patient Safety Agency functions
Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.
Matched on
terms: significant
Inquiry recommendation
57match
MAI-152 - Recording equipment for incident commanders
The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that all those who may be required to take up a command position in the event of a Major Incident are issued with a means to record what they say, hear and see unless there are good reasons why...
Matched on
terms: event
Article 2 learning point
55match
Mr North — HMP Whitemoor - LP 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
Matched on
terms: event, significant
Inquiry recommendation
53match
COVID-M1.6 - Triennial Pandemic Exercises
The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak to multiple waves over a number of years; include a broad range of those involved in pandemic preparedness...
Matched on
terms: event
CQC action
53match
Fairglen Residential Home
The provider must inform CQC of notifiable events.
Matched on
terms: event
IMB recommendation
52match
London STHF (2024)
The Board stopped receiving Safer Detention Reports in July 2023 and despite many requests, these have not been forthcoming. This means that we do not have access to the data to enable us to monitor Suicide and Self Harm Warning Forms, Vulnerable Adult Warning Forms and Use of Force. After repeated requests at every Board meeting, we were...
Matched on
terms: event
PFD report
49match
Julie Morrey
A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.
Matched on
classifier match
PFD report
49match
Vivien Brunning
Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Matched on
classifier match
CQC action
48match
Universal Care - Beaconsfield
The provider failed to ensure it notified us of events it was legally responsible to inform us.
Matched on
terms: event
CQC action
48match
The Homestead (Crowthorne) Limited
The registered person failed to notify the Commission of notifiable events, 'without delay'.
Matched on
terms: event
Committee recommendation
48match
#33 - University Hospitals of Leicester NHS Trust faces significant audit and control weaknesses.
At the time of our evidence session, University Hospitals of Leicester NHS Trust (UHL) had yet to publish its 2021–22 Annual Report and Accounts. UHL’s auditor was not able to obtain sufficient, appropriate evidence upon which to form an opinion for 2019–20, and issued an adverse audit opinion for 2020–21, due to system and control weaknesses resulting in...
Matched on
terms: significant
PFD report
45match
Elsie May Treece
Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Matched on
classifier match
PFD report
45match
Richard Moss
Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Matched on
classifier match
Inquiry recommendation
45match
MAI-81 - Improve NWFC Major Incident record-making
North West Fire Control should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Matched on
classifier match
Inquiry recommendation
45match
MAI-71 - Improve NWAS Major Incident record-making
North West Ambulance Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Matched on
classifier match
Inquiry recommendation
45match
MAI-38 - Improve GMP Major Incident record-making
Greater Manchester Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Matched on
classifier match
Inquiry recommendation
45match
MAI-33 - Improve GMFRS Major Incident record-making
Greater Manchester Fire and Rescue Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Matched on
classifier match
Inquiry recommendation
45match
MAI-19 - Provide recording equipment to control room personnel
Consideration should also be given by those organisations to the provision of such equipment to key personnel within control rooms.
Matched on
classifier match
Inquiry recommendation
45match
MAI-14 - Improve BTP Major Incident record-making
British Transport Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Matched on
classifier match
Inquiry recommendation
44match
12 - Review incident investigation structures
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements for additional training. The Trust should ensure that robust documentation is used, based on a recognised system, and...
Matched on
classifier match
CQC action
44match
The Newcastle Clinic
The service should have a system to identify, record, review and report incidents.
Matched on
classifier match
Inquiry recommendation
44match
F114 - Complaints handling
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Matched on
terms: event
IMB recommendation
44match
Swaleside (2022)
The IMB is concerned at the occasional failure to be invited to serious incidents and planned moves to the CSRU and would appreciate the necessity for this to be reiterated to all senior staff.
Matched on
terms: failure
IMB recommendation
43match
Exeter (2020)
Will the Governor continue to build on improvements to notify the Board of serious and other notifiable incidents or events?
Matched on
terms: event
PHSO casework decision
43match
P-004303 - King's College Hospital NHS Foundation Trust
Mrs F complains that the Trust discharged her son Mr F when it shouldn't have done and did not communicate with her about this discharge sufficiently. She also complains about the Trust's protracted complaints procedure and its failure to record Mr F's death as a serious patient safety incident until 35 months after his death.
Matched on
terms: failure
LGO / SPSO decision
43match
21-010-289 - Sheffield City Council
Summary: Miss H complains the Council and Trust significantly delayed her son J’s Education, Health and Care Plan annual review, and J did not receive the 1-1 speech and language therapy sessions in his plan. There was fault by the Council and Trust. There were long delays in the annual review process, and in the response to Miss...
Matched on
terms: significant
CQC action
43match
Meadow Green
The provider must ensure that notifications of other incidents are made to CQC in line with Regulation 18 (2) (e).
Matched on
classifier match
CQC action
43match
The Lodge Care Home
Notifications of other incidents
Matched on
classifier match
LGO / SPSO decision
42match
25-001-155 - West Northamptonshire Council
Summary: Miss X complained the Council failed to adhere to the statutory timeframes for issuing her child, Z’s, Education, Health and Care Plan, and it failed to provide Z with access to suitable education. We find the Council at fault for a delay in issuing a final Education, Health and Care Plan and a delay in securing suitable...
Matched on
terms: log, significant
LGO / SPSO decision
42match
201709143 - Fife NHS Board
Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity). Mr C complained that the service refused to offer him bariatric surgery after he attended a weight management programme....
Matched on
terms: event, log
Inquiry recommendation
41match
F99 - National Patient Safety Agency functions
The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.
Matched on
classifier match
Inquiry recommendation
41match
POH-17 - Establish standing public body to administer future redress schemes
As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Matched on
classifier match
Inquiry recommendation
41match
POH-13 - Close HSS Dispute Resolution Procedure when HSSA opens
The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA opens should be eligible to join the Dispute Resolution Procedure.
Matched on
classifier match
CQC action
41match
TerraBlu Homecare
Registered persons had failed to notify CQC in a timely manner about incidents that had occurred.
Matched on
classifier match
CQC action
41match
Ability Associates Limited - 77 The Street
The registered manager had not ensured they notified the Care Quality Commission of allegations of abuse and incidents reported to the police.
Matched on
classifier match
CQC action
41match
Dr French Memorial Home Limited
Notifications of other incidents
Matched on
classifier match
CQC action
41match
Benedict House Nursing Home
The provider must ensure that the Care Quality Commission is notified of any allegation of abuse in relation to a person using the service.
Matched on
classifier match
CQC action
40match
Ashville House
Records of incidents, accidents and falls were not fully collated, showing the level of impact or lessons learnt.
Matched on
classifier match
Inquiry recommendation
40match
IHRD-17 - Recording Changes in Accountability
Any change in clinical accountability should be recorded in the notes.
Matched on
classifier match