Medical device display errors
Clinician misinterpretation of unrecordably low critical values displayed on medical devices (e.g., glucose as '---↓').
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
47 PFD reports
16 committee recs
47 HSSIB recs
5 CQC actions
5 patient safety alerts
1 Scottish FAI
1 Article 2 learning point
6 PHSO decisions
6 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(47)
Kenneth Smalley
Concerns: The coroner noted concerns regarding an operating table moving uncontrollably due to issues with its handset, including possible fluid ingress and a non-functional emergency stop button. There was also a lack of hospital review for similar equipment and insufficient pre-operative checks for handset integrity.
Response (Wrightington Wigan and Leigh NHS): • The Trust developed specific checklists for each type of operating table and conducted thorough safety checks using qualified technicians. • A Standard Operating Procedure for theatre preparation, including daily … (AI summary)
Overdue
Arthur Brockett-Deakins
Concerns: Concerns involved midwives' interpretation and escalation of abnormal CTG traces, particularly the inappropriate application of guidelines during a slow second stage of labour. The coroner also noted issues with CTG machines potentially displaying maternal heart rate as fetal heart rate due to an unknown multiplication factor, and the slow replacement of older models lacking differentiation.
Response (N.I.C.E): • NICE stated that its clinical guideline on Intrapartum Care (CG55) was currently being updated. • NICE reported that the update process included a re-examination of evidence on fetal assessment … (AI summary)
Response (Medicines Healthcare Products Regulatory Agency): • The Medicines Healthcare Products Regulatory Agency (MHRA) identified the cardiotocograph (CTG) model in use and contacted the manufacturer to determine if they had been notified of the incident or … (AI summary)
Response (NMC): • The NMC stated it would investigate information regarding a specific midwife as a new fitness to practice referral. • The NMC confirmed that policy and training on supervisory investigations … (AI summary)
Response (Department of Health): • The model of private midwifery provision described in the case was discontinued in July 2010 and no longer operates. (AI summary)
Responded
Archie Hames
Concerns: Independent expert testing found that the combined use of a specific tracheostomy tube and a particular Velcro strap compromised the tube's integrity, likely causing its detachment. The coroner also raised concerns about the broader implications for continued use of Velcro strap attachments with tracheostomy tubes.
Response (Department of Health): • The specific type of tracheostomy tube flange identified as being damaged by Velcro is no longer available on the market. • Manufacturers clarified instructions for use to warn against … (AI summary)
Overdue
Marjorie Phillips
Concerns: The coroner noted concerns regarding a hoist sling's tendency to "bag" at the sides, which could allow a patient to fall if they leaned to one side during transfer.
Response: • Sunrise Medical Limited provided Instructions for Use (IFU) documents for their hoists. • The IFUs advise users to check slings for wear or damage, including 'bagging,' before each use. … (AI summary)
Overdue
Jackson Mitchell
Concerns: The coroner noted damage to the liver from concentrated feeding fluid, potentially linked to the low-lying position of an umbilical venous catheter, a placement currently acceptable to most doctors. Concerns were raised about the risk of extravasation from UVCs and ongoing investigations into optimal catheter positioning.
Response (The Queen Elizabeth Hospital NHS Trust): • The Trust introduced a new X-ray review checklist requiring senior clinician review and signing for all X-rays, including those checking line and tube positions. • Regional guidelines for umbilical … (AI summary)
Overdue
Gaenor Moore
Concerns: The coroner noted the absence of an alarm on the oxygen concentrator to indicate a loss of oxygen flow if the humidifier screw cap was not properly engaged, along with insufficient training and literature on this specific risk.
Response (Dolby Vivsol): • The company will modify its humidifier leaflet to provide increased awareness of the impact of incorrect bottle connection and will place greater emphasis on confirming oxygen flow from the … (AI summary)
Response (Invacare): • Invacare stated it does not produce or provide humidifier bottles in the United Kingdom. • Invacare concluded that adding an alarm to detect loss of oxygen flow at the … (AI summary)
Response (Salter Labs): • Salter Labs conducted an internal multi-disciplinary technical design review of the humidifier thread design in December 2014. • Salter Labs will add two new statements to product labeling regarding … (AI summary)
Responded
James Fyfe
Concerns: The coroner identified a design and maintenance issue allowing a trolley's cot side to remain raised but unlocked, with uncertainty about its inclusion in maintenance schedules. It was also noted the MHRA did not escalate this known risk to other hospital trusts.
Response (Medicines Healthcare Products Regulatory Agency): • The Medicines Healthcare Products Regulatory Agency (MHRA) conducted a review of the incident in 2015, including visits to the Royal Berkshire Hospital and the manufacturer. • The MHRA advised … (AI summary)
Response (AneticAid): • AneticAid commenced a programme of QA3 end-user training with Royal Berkshire Hospital staff. • AneticAid stated it would actively continue to support the end-user training programme. (AI summary)
Response (Royal Berkshire NHS Trust): • The Trust contracted Anetic Aid Limited (AA) for periodic inspection and maintenance of its QA3 trolleys, and updated its Clinical Engineering Checklist to detail required inspection checks. • The … (AI summary)
Responded
Brian Marks
Concerns: The coroner noted the similar appearance of PEJ and PEG tubes could lead to confusion, suggesting a simple colour coding system to aid differentiation when the tubes are in situ.
Response (Department of Health): • The Medicines and Healthcare Products Regulatory Agency (MHRA) will bring the issue of tube misidentification to the attention of relevant Standards Committees. • The MHRA will include the risk … (AI summary)
Responded
Steven Curtis
Concerns: The coroner raises concerns about the safety of Maplin N19KJ telescopic ladders, noting approximately 43,000 units were sold before withdrawal due to safety issues. Further investigation is sought regarding the accident ladder's origin and a review by Maplin.
Overdue
Dilys Jenkins
Concerns: The coroner raises concerns that standard tracheostomy tube lengths may be inappropriate for the increasing size of the population, potentially contributing to complications like dislodgement. The Intensive Care Society is encouraged to influence the industry to address this issue.
Overdue
Geoffrey Parry
Concerns: Concerns included a recurring problem with investigative test results not being available with patient notes or electronically uploaded, and the absence of a protocol or labels for intravenous lines, which contributed to an accidental disconnection.
Response: • The Health Board reviewed systems and processes for ECG investigations and is developing an improvement plan for the MUSE system. • An improvement plan for intravenous infusion labelling practice … (AI summary)
Responded
James Hedge
Concerns: The coroner notes that advice and guidance for insulin pumps do not adequately highlight dangers of misuse, and diabetic patient education lacks focus on the rapid life-threatening nature of unmanaged hyperglycaemia.
Response (NHS England): • NHS England will consider issues related to the risks from incorrect use of insulin pumps and the management of hyperglycaemia as part of a review into supporting structured education. (AI summary)
Response (Medicine and Healthcare Products Regulatory Agency): • The Medicine and Healthcare Products Regulatory Agency (MHRA) published a Medical Device Alert (MDA) on 15 August 2016 to inform healthcare providers of new instructions for changing insulin cartridges … (AI summary)
Response (Roche Diabetes Care Limited): • Roche Diabetes Care Limited issued a Field Safety Notice in May 2016 to reinforce existing advice on correct insulin pump cartridge insertion and emphasize related risks. • The company … (AI summary)
Response (Welsh Government): • The Welsh Government noted that the Medicines and Healthcare Products Regulatory Agency (MHRA) issued a Medical Device Alert concerning incorrect cartridge insertion and under-delivery of insulin. • The Welsh … (AI summary)
Responded
Joseph De Pellergrino-Farrugia
Concerns: The coroner noted that the chair was not fitted with sensors to detect a foot in its mechanism, which could have prevented a crushing injury and released the foot.
Response: • AJ Way and Co Ltd stated it can fit sensor strips or protective screens to the underside of the chair's side and back when requested by retailers. • The … (AI summary)
Overdue
Glenys Pollitt
Concerns: The coroner noted differing practices in the use of high-resolution screens for X-ray viewing and a tendency for clinicians to focus on expected findings. Concerns were also raised about the unclear process for escalating cases to consultant level and critical care.
Response (Stockport NHS Trust): • The Radiology Systems Manager drafted a document detailing the location and access to high-resolution screens, awaiting board sign-off. • The Emergency Department and Acute Medicine teams completed morbidity and … (AI summary)
Responded
Peter Cotter
Concerns: The clinical decision support software system did not register a head injury for a patient receiving anticoagulant drugs. The coroner recommends reviewing the triage system to ensure all head injuries are recognised and treated as emergencies.
Response (NHS England): • NHS Pathways identifies and assesses head injuries, including for patients on anticoagulant treatment. • The head injury assessment questions align with the latest NICE guidelines. • The specific case … (AI summary)
Response (South Central Ambulance Service NHS Trust): • The Trust stated it is unable to make changes to the national NHS Pathways clinical decision support software system. • The Trust's EOC Clinical Assurance & Training Manager notified … (AI summary)
Responded
Donald Till
Concerns: The coroner noted the unavailability of previous medical records, the absence of a rapid-tilt trolley for anaesthetisation, and issues with equipment, including a faulty bronchoscope. Procedural concerns also included the non-use of cricoid pressure and NG tubes.
Response (University Hospitals of North Midlands): • The Trust is establishing a fully electronic case notes system and has existing processes for accessing medical records for urgent admissions. • Measures were taken to ensure a rapid … (AI summary)
Responded
Freddie Dobinson-Evans
Concerns: The coroner noted that genetic test results indicating a pathogenic gene mutation were misinterpreted, leading to a family being incorrectly informed the results were "absolutely normal." This situation carries a risk of similar miscommunications impacting other children.
Response (Barts Health NHS Trust): • A meeting was held with Great Ormond Street Hospital (GOSH) genetics lab personnel to discuss the concerns. • Changes to the genetic test results format were initiated, and a … (AI summary)
Overdue
Norman Pirie
Concerns: The coroner is concerned that medical devices are being used in non-emergency procedures outside manufacturer's instructions, which increases the risk of device failure and the need for high-risk emergency open surgery.
Response (Barts Health NHS Trust): • The Trust will implement steps to improve communication pathways between clinicians, GPs, and patients. • The Trust will institute separate and joint planning meetings for detailed technical discussions on … (AI summary)
Responded
Jeanette Robinson
Concerns: The coroner noted the lack of an alarm or warning system on a medical air mattress and turning device, which meant there was no alert when the power cable dislodged, causing deflation.
Response (Cornwall Council): • The Council stated that all Nimbus systems in the community had been replaced with a new mattress system called Elite. • The Council confirmed that all Nimbus stock had … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) confirmed it had no record of the incident as it had not been reported. • The manufacturer, Arjo Huntleigh, logged the … (AI summary)
Responded
Doris Clark
Concerns: A doctor prescribed morphine without knowing the dose already given by paramedics. The coroner identified a risk arising from the differing units of measurement for opiate medication used by pre-hospital and hospital services.
Overdue
Susan Warby
Concerns: Packaging for intravenous fluids used with arterial line transducer sets lacks distinctiveness, leading to errors. Additionally, medical staff were not using the correct technique when drawing blood samples from arterial lines, which compounded the issue.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare products Regulatory Agency (MHRA) has published guidance for the pharmaceutical industry on optimising the presentation of information on labelling to reduce the likelihood of error. … (AI summary)
Response (Dept. of Health and Social Care): • The West Suffolk NHS Foundation Trust implemented enhanced procedures, including the introduction of clear medication bags and changes to fluid checking processes. • The Trust also implemented new training … (AI summary)
Responded
Ivan O’Neill
Concerns: The patient was positioned out of sight from the nurses' station, and the dialysis equipment's alarm was insufficiently sensitive to promptly detect significant blood loss from a dislodged needle.
Overdue
Leslie Harris
Concerns: The coroner raised concerns regarding the interpretation of Public Health England guidance on patient movement to Covid-19 isolation wards, noting that varied interpretations across trusts could put vulnerable patients at risk of infection.
Response (NHS England): • The national IPC guidance was updated on 20 August 2020 to include examples for managing COVID-19 risks through specific pathways. • A further update to the guidance was published … (AI summary)
Response (UK Health Security Agency): • Public Health England (PHE) updated its guidance on managing staff and exposed patients, including on 4th April 2020 and 15th May 2020, to strengthen advice on isolation and cohorting. … (AI summary)
Responded
Stephen Oakes
Concerns: Coroner noted insufficient product description and sales staff training regarding an enteral tube's restricted bore, impacting hospital evaluation and nursing staff's response to drainage issues. Concerns also highlighted the product's continued promotion despite safety notices.
Response (Medicines and Healthcare Products Regulatory Agency): • The manufacturer updated product labelling for Carefeed devices to remove drainage as a secondary intended use. • The agency contacted the British Association for Parenteral and Enteral Nutrition (BAPEN) … (AI summary)
Response (GBUK Group Ltd): • GBUK Group Ltd revised device labelling and Instructions For Use (IFU) to remove references to drainage and include warnings about ENFit connector limitations for larger tube sizes. • The … (AI summary)
Response (University Hospitals of North Midlands NHS Trust): • A new proforma for evaluating equipment has been designed and will be used to collect user feedback during initial trial periods. • Local Safety Standards for Invasive Procedure (LocSSIP) … (AI summary)
Response (NHS England NHS Improvement): • NHS England shared the report with the Medicines and Healthcare products Regulatory Agency (MHRA). • The Patient Safety Team is reviewing the National Reporting and Learning System (NRLS) for … (AI summary)
Responded
Peter Hussey
Concerns: The coroner noted an Enteral 14FR tube's en-fit connector restricted its effective bore, causing insufficient drainage, raising concerns about inadequate product description, insufficient manufacturer and hospital evaluation, and nursing staff not aspirating tubes.
Response (NHS England): • NHS England shared the report with the Medicines and Healthcare products Regulatory Agency (MHRA) for concerns relevant to their area of work. • The Patient Safety Team is reviewing … (AI summary)
Response (GBUK Group Ltd): • The company revised device labelling and Instructions For Use (IFU) to remove all references to drainage and added warnings about limitations for drainage use. • The company contacted NHS … (AI summary)
Response (University Hospitals of North Midlands NHS Trust): • A new proforma for evaluating equipment has been designed, and the Trust will use it to collect user feedback during initial trial periods. • Local Safety Standards for Invasive … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The manufacturer updated product labelling for Carefeed devices to remove 'drainage' as a secondary intended use. • The MHRA is engaging with the manufacturer regarding updating their website's Instructions … (AI summary)
Responded
Don Fernandes
Concerns: The coroner identified challenges in reliably confirming NG tube placement in infants, particularly with pH testing when medication is used and limiting X-ray exposure. Concerns also included staff misunderstanding individualised policy adjustments.
Response (Oxford University Hospitals NHS Foundation Trust): • No subsequent Never Events or incidents related to NG tubes have been identified since the reported event. • An audit of PICC records confirmed that NG tubes in situ … (AI summary)
Responded
Kishorkumar Patel and Kofi Aning
Concerns: The coroner noted concerns about the non-standardised colour coding, numerous types, and variable optimal positions of breathing system filters and HMEs, leading to widespread confusion and a lack of knowledge among ICU staff. This situation requires review, simplification, and standardisation.
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA contacted eight manufacturers to search their databases for similar incidents, identifying four. • The MHRA will engage with the medical device safety officers network to raise awareness … (AI summary)
Response (Professor): • The response suggested standardising the colour coding of filters. • The response recommended ceasing the manufacture of bacterial/viral filters with sampling ports unless essential, in which case they should … (AI summary)
Response (Royal College of Anaesthetists and The Faculty of Intensive Care Medicine): • The Royal College of Anaesthetists and The Faculty of Intensive Care Medicine confirmed support for standardisation of labelling and colour coding of breathing circuit filters and indicated they would … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) stated it would work with stakeholders to explore the impact of interim measures, such as reducing filter types, on patient safety. … (AI summary)
Responded
Chimezie Daniels
Concerns: The coroner noted that CPAP machines use the same alarm for minor leaks and total oxygen cessation, which complicated identifying the cause of a patient's low oxygen saturations when multiple alarms were sounding simultaneously.
Response (NHS England): • NHS England's national patient safety team worked with the British Thoracic Society to develop guidance for Respiratory Support Units, which included recommendations for local protocols to detect CPAP/NIV disconnection. … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) reviewed the designated international standard for alarm systems in medical electrical equipment. • The MHRA is engaging with the Association of … (AI summary)
Responded
Andrew Cook
Concerns: The coroner noted potential under-reporting of PEG allergy and a need for more research into its effects. Concerns were raised about the lack of clear information on medical product labelling regarding PEG's presence, dose, and molecular weight, compounded by inconsistent nomenclature.
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA plans to launch a Devices Safety Information webpage and issue a Drug Safety Update to raise awareness of PEG/macrogol in medical devices and medicines, including nomenclature variations. … (AI summary)
Responded
Ann Geraghty
Concerns: The coroner raises concerns about Philips central cardiac monitoring stations (model M3151) where alarms self-terminate when certain abnormal heart rhythms correct themselves, risking future deaths if not addressed by the manufacturer.
Response (Philips Healthcare): • Philips Healthcare conducted an investigation into the reported incident, including a review of available information and worldwide complaints. • Philips Healthcare performed a site visit to Good Hope Hospital, … (AI summary)
Response (University Hospitals Birmingham NHS Foundation Trust): • The Trust issued an email to all cardiology staff detailing the alarm system's functionality and discussed this information in ward safety huddles. • The Trust is working with Philips … (AI summary)
Responded
Diana Reay
Concerns: Concerns were raised that numerous doctors incorrectly interpreted scans, mistaking a fluid-filled cyst for a full bladder. This led to unnecessary re-catheterisations of the patient.
Overdue
Mary Land
Concerns: The coroner noted the Philips Respironics AF 541 mask's 'push on' connection to the BIPAP ventilator tubing is prone to coming undone, especially with a filter. A more robust docking mechanism is suggested.
Response (Mid Yorkshire Hospitals): • The Trust completed four actions identified during a significant event investigation by 4 August 2021. • One completed action involved exploring manufacturer or other solutions for greater tubing circuit … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA instructed Philips to report the incident and requested all available information established during their investigation. • The MHRA asked Philips to investigate the potential impact of the … (AI summary)
Response (Philips Electronics UK Ltd): • Philips concluded that the AF541 mask and Trilogy EVO ventilator operated as designed. • Philips noted that the facility did not follow manufacturer's instructions and did not respond appropriately … (AI summary)
Response (Department of Health and Social Care): • Philips Respironics extended its investigation to include the connection tubing and facemask. • The MHRA requested Philips to investigate the potential impact of using a filter in the facemask. … (AI summary)
Responded
Van Tuyen
Concerns: The coroner noted the continued occurrence of deaths from misplaced nasogastric tubes, which are 'never events', and identified a lack of a unified approach across NHS Trusts to prevent these avoidable incidents.
Response (Department of Health and Social Care): • NHS England supported local implementation of nasogastric tube safety guidance, including funding eLearning for x-ray interpretation and developing easy reference safety checks. • The Healthcare Safety Investigation Branch (HSIB) … (AI summary)
Responded
Sangeerth Girirathan
Concerns: Alarms on ICU patient monitors were disengaged, meaning staff were not alerted when the patient's oxygen saturations fell, resulting in cardiac arrest. The coroner recommends staff be reminded of the need for alarms to remain active.
Response (Department for Transport): • The Department for Transport outlined existing GB domestic drivers’ hours rules and Working Time Regulations 1998 for goods vehicles under 3.5 tonnes. • The Driver and Vehicle Standards Agency … (AI summary)
Response (NHS Milton Keynes): • Communication has been issued to critical care staff regarding the appropriate use of alarms, and point prevalence surveys are being conducted to support and educate staff. • Staff have … (AI summary)
Responded
Jade Revell
Concerns: The SystemOne computer programme can obscure blood test results when minimised, lacking a scroll feature. This means abnormal results may be missed and unactioned, as the programme prevents them from being more visibly highlighted.
Response (TPP LTD): • TPP identified a system change to address the scroll bar behaviour in one of the result review views. • This change, ensuring the scroll bar reset to the top … (AI summary)
Responded
Devon Turner
Concerns: The coroner identified concerns about the reliability, suitability, and ease of use of SATS machines provided for home monitoring, particularly after one machine ceased to function and alarms from another device were not responded to.
Response (NHS England): • NHS England contacted the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the concerns raised. • NHS England will review any further considerations from the MHRA's ongoing investigation. • … (AI summary)
Response (Medtronic): • Medtronic conducted functional testing and downloaded data from the PM100N device on multiple occasions in May and July 2022. • Medtronic reported the incident to the Medicines and Healthcare … (AI summary)
Response (Buckinghamshire Oxfordshire and Berkshire West Integrated Care Board): • The Integrated Care Board (ICB) reported that a Joint Agency Response meeting and a Child Death Review meeting were held with partner organisations. • The ICB stated that the … (AI summary)
Responded
Lauren Smith
Concerns: The coroner identified that paramedics incorrectly interpreted an abnormal ECG, failing to recognise key indicators of a cardiac event, and provided the patient with incorrect information. Concerns were raised regarding the effectiveness and qualitative assessment of ECG interpretation training for paramedics.
Response (West Midlands Ambulance Service): • The Trust implemented a programme of work between January and September 2023, which included issuing articles, delivering CPD sessions, engaging with Zoll Medical for ECG training, and establishing a … (AI summary)
Response (Health and Care Professions Council): • The Health and Care Professions Council (HCPC) added the individual's name to its Watchlist. • The HCPC stated it would take the raised concerns into account if the individual … (AI summary)
Response (Health Services Safety Investigations Body): • The Health Services Safety Investigation Body (HSSIB) held an Intelligence Review Meeting on 20 December 2023. • The Regulation 28 Report was considered during this meeting, and further exploratory … (AI summary)
Response (University of Wolverhampton): • The university stated it would incorporate interpretation of 12-lead ECGs into Objective Structured Clinical Examinations. • The university stated it would add a 12-lead ECG interpretation workbook to the … (AI summary)
Response (CQC): • The CQC confirmed that the training needs of one staff member involved in the incident have been addressed. • The CQC stated that the training needs of a second … (AI summary)
Responded
Thomas Wakefield
Concerns: The coroner raised concerns that NICE and international guidance do not sufficiently caution clinicians about the risk of misidentifying abdominal aortic aneurysm and acute pancreatitis due to their similar presenting features. The guidance does not specifically require the exclusion of an aneurysm when a pancreatitis diagnosis is uncertain.
Response (NHS England): • NHS England stated that responsibility for the relevant clinical guidelines does not fall within its remit and suggested the coroner refer concerns to the responsible organisations. • Clinical leads … (AI summary)
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence stated it would review section 1.2 of its guideline on pancreatitis. • The National Institute for Health and Care Excellence indicated … (AI summary)
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence (NICE) confirmed the completion of an amendment to its guideline for pancreatitis (NG104). • The amendment revised the wording regarding the … (AI summary)
Responded
Ben Harrison
Concerns: The coroner identified that the design of BOC CD Oxygen cylinders, specifically the two-valve operation, is confusing for users in high-pressure situations, which can lead to delays in oxygen delivery. This issue persists despite staff training and reports made to the manufacturer and regulatory bodies.
Response (BOC): • BOC provides comprehensive user information through cylinder labelling, product characteristics, patient leaflets, online instructions for use, and instructional videos. • BOC modified the cylinder valve handwheel tamper-evident cover by … (AI summary)
Responded
Michael Walton
Concerns: The unavailability of the surgeon's preferred cannula due to supply issues led to a shorter-tipped alternative being used. This cannula contributed to its dislodgement and Mr Walton's death, highlighting risks when equipment choice is restricted.
Response (NHS England): • NHS England engaged with Newcastle upon Tyne Hospitals NHS Foundation Trust regarding the concerns raised. • The Theatre Department at Newcastle upon Tyne Hospitals NHS Foundation Trust permanently suspended … (AI summary)
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England, the Medicines and Healthcare products Regulatory Agency, and the Care Quality Commission. • The Department confirmed that the supply disruption of the … (AI summary)
Responded
June Liddell
Concerns: Concerns were raised regarding the device's Instructions for Use, which omitted a critical error message and the significance of disappearing control icons. Additionally, the unique alarm function was unknown to users, and manufacturer maintenance lacked a wear-and-tear identification process.
Response (LivaNova): • LivaNova stated that the error message and the disappearance of icons are clear indicators to trained perfusionists, and no additional explanation in the Instructions for Use is necessary. • … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) conducted an investigation into the LivaNova S5 heart lung machine. • The MHRA recommended that the manufacturer update the Instructions for … (AI summary)
Responded
Sybil Morgan-Gray
Concerns: The coroner raises concerns that blood gas machine displays for unrecordably low blood glucose levels can be misinterpreted, potentially delaying appropriate clinical responses. The report notes the display '- - -↓' may be seen as an unanalysable sample rather than an extremely low reading.
Response (Medicines Healthcare products Regulatory Agency): • The MHRA investigated whether the interpretation of unrecordably low glucose readings was a wider issue across point of care analysers and confirmed no further safety signals had been identified … (AI summary)
Responded
Jake Lawler
Concerns: Clinicians regularly miss or misunderstand ECG readings, and there is no clear national guidance for the pathway of children with paediatric exercise-induced syncope. Additionally, the assessment for exercise-induced asthma was insufficient, delaying the diagnosis of an underlying cardiac condition.
Response (Department of Health and Social Care): • The Department of Health and Social Care noted that Manchester University NHS Foundation Trust is undertaking several improvements, including developing paediatric ECG e-learning, reviewing referral guidelines, and creating a … (AI summary)
Responded
Kathleen Gregory
Concerns: The coroner noted concerns regarding a paramedic's interpretation of a ReSPECT form, where it was understood that resuscitation should not be attempted for choking, even if reversible. This approach was identified as potentially inconsistent with the form's intended application.
Response (Beccles Medical Centre): • A significant event analysis of the case, focusing on ReSPECT form completion and wording, is scheduled for September 2025. • A practice-level review of clinician training on ReSPECT forms … (AI summary)
Responded
Melanie Walker
Concerns: The coroner raises concerns that heart monitors in other hospital trusts may not re-alert staff if a lead remains disconnected after an initial acknowledgment, creating a risk that cardiac events could go undetected. This deficiency means patients may not be appropriately monitored until equipment is reconfigured and staff are trained.
Response (Philips Electronics UK Ltd): • Philips reset the "ECG Leads Off" technical alarm to the factory default configuration for the hospital involved. • Philips stated it does not propose further action to the default … (AI summary)
Response (NHS England): • Learning from the Patient Safety Incident Investigation was shared via Speciality and Divisional Governance structures and Trust Governance structures. • Heart monitors were reconfigured so that if an 'ECG … (AI summary)
Response (Department for Health and Social Care): • The Medical and Healthcare products Regulatory Agency (MHRA) published a Field Safety Notice from Philips on its gov.uk platform. • The MHRA is assessing the notice, which includes a … (AI summary)
Responded
Margaret Grimsley
Concerns: The coroner raised concerns regarding the apparent absence or non-use of an upper alarm setting on bedside oxygen meters, which risks over-oxygenation. There was also a lack of clarity on whether such an alarm can be set or if it is standard practice.
Response (Shrewsbury and Telford Hospital NHS Trust): • The Trust clarified that wall-mounted patient monitors have upper oxygen alarm functionality, but this is not used in a ward environment due to clinical considerations and regional practice. • … (AI summary)
Responded
Ismaeel Islam
Concerns: The coroner raises concerns that the monitor manufacturer has not yet made a decision regarding the hospital's request to lock or default alarm volumes to maximum, which could enhance patient safety.
Response (Masimo UK): • Masimo stated that the Rad-97® monitor is shipped with the SpO₂ Alarm Volume setting at its maximum default. • Masimo confirmed that the device is equipped with an Alarm … (AI summary)
Responded
Select committee recommendations(16)
#12 —
Recommendation: The Department of Health and Social Care should make primary care workers aware of the potential for a link between autoimmune conditions and breast implants to ensure that women presenting with symptoms following implantation are not dismissed. (Recommendation, Paragraph 47)
Response status not verified
#11 —
Recommendation: The Government should commission research to better understand the health impacts of breast implants, including their potential impacts on women with pre-existing auto-immune conditions. The research needs to be a mix of clinical research, including on the health impacts of …
Response status not verified
#10 —
Recommendation: Evidence of concentrations of siloxanes in women’s bodies outside of their implants is particularly concerning. The mental health impacts of knowing that chemicals, which are being banned in other uses due to their toxicity, are circulating in your body should …
Response status not verified
#9 —
Recommendation: There is growing concern that a number of women are experiencing serious health impacts after receiving breast implants, with many reporting symptom improvements following explantation. While evidence of a definitive link between these symptoms and breast implants has not been …
Response status not verified
#8 —
Recommendation: The Government should increase the information available on the approval of medical devices to allow interested parties to see not only what devices are approved but the evidence base underpinning the decisions to approve them. (Recommendation, Paragraph 36)
Response status not verified
#7 —
Recommendation: The PIP implant scandal involved substandard implants being given to women for many years without detection. The new post-surveillance regime for breast implants must include regular testing of approved implants to ensure continued compliance with safety standards. (Recommendation, Paragraph 35)
Response status not verified
#6 —
Recommendation: A mandatory cooling-off period of at least two weeks should be introduced between the initial consultation and surgery for breast implants, ensuring patients have sufficient time to consider risks and alternatives before making a commitment. (Recommendation, Paragraph 27)
Response status not verified
#5 —
Recommendation: We note that the registry is currently overseen by the soon-to-be abolished NHS England. The Government should take steps to ensure that the improvements we call for are not delayed by internal reorganisation. (Recommendation, Paragraph 26)
Response status not verified
#4 —
Recommendation: The Government should introduce mandatory recording of breast implant and explant procedures and instances of adverse outcomes in the Breast and Cosmetic Implant Registry by the end of 2026. We welcome the Government’s acknowledgement that the registry requires improvement. The …
Response status not verified
#3 —
Recommendation: Without mandatory participation in the Breast Implant Registry and the regular publication of outcome data, surgeons cannot provide patients with comprehensive risk information. This undermines the principle of informed consent. Many individuals feel inadequately informed before surgery and the absence …
Response status not verified
#2 —
Recommendation: While there is a judgement to be made over whether the NHS should offer replacement implants to women affected by the PIP implants scandal, women with PIP implants who wish to have them removed should be able to have that …
Response status not verified
#1 —
Recommendation: The PIP implant scandal exposed failures that continue to affect women more than a decade later. Official assurances that PIP implants pose no health risks appear to be based on limited long-term research and underplay the mental health impacts on …
Response status not verified
#17 —
Recommendation: We are aware that the Medicines and Healthcare products Regulatory Agency (MHRA), the government’s regulatory body which approves medical devices, approved 51 https://www.gov.uk/government/news/staggered-rollout-of-coronavirus-testing-for-secondary-schools- and-colleges; https://www.gov.uk/government/publications/coronavirus-covid-19-asymptomatic-testing-in- schools-and-colleges/coronavirus-covid-19-asymptomatic-testing-in-schools-and-colleges; https://www.gov.uk/ government/news/all-students-offered-testing-on-return-to-university 52 Qq 13, 16–17, 118 53 C&AG’s Report paras 1.28–1.29 54 Q …
Response attribution not verified
#16 —
Recommendation: A number of significant commentators, including the British Medical Association and British Medical Journal, have raised concerns about the effectiveness and risks of mass testing with LFD tests.55 A particular issue raised is the relative accuracy of LFD tests compared …
Response attribution not verified
#5 —
Recommendation: The performance requirements on direct-to-consumer genomic tests under the current regulations focus on a genomic test’s analytical performance, not its clinical performance. For a medically-relevant test, however, clinical performance is fundamental to how the test will be used by a …
Response attribution not verified
#8 —
Recommendation: The OPSS’s lack of data has slowed its response to some serious areas of harm, such as small, high-powered magnets that led to 40 paediatric admissions in the UK in 2020 alone. Issues with these magnets have been reported for …
Response attribution not verified
HSSIB safety recommendations(47)
The use of an appropriate flush fluid with arterial lines
HSIB recommends that the Medicines and Healthcare products Regulatory Agency communicates to all relevant stakeholders and acts on the available evidence concerning the management of the risks associated with arterial transducer line sets. The intention of this safety recommendation is …
Safety Recommendation
The use of an appropriate flush fluid with arterial lines
HSIB recommends that the Medicines and Healthcare products Regulatory Agency reviews and acts on the available evidence to regulate for the use of pressure infusion bags that allow fluid labels to be read when inflated. The intention of this safety …
Safety Recommendation
Implantation of wrong prostheses during joint replacement surgery
The National Joint Registry (NJR) changes the response when data is entered into the registry suggesting the wrong prosthesis has been implanted due to incompatible manufacturers, so that it is consistent with the response when data indicates the wrong size …
Safety Recommendation
Implantation of wrong prostheses during joint replacement surgery
The British Standards Institute amends existing standards for prosthesis labels to include details of design that make them easier to read in operating theatres. The American Society for Testing and Materials’ ‘Standard Guide for Presentation of End User Information for …
Safety Recommendation
Insertion of an incorrect intraocular lens
The Medicines and Healthcare products Regulatory Agency should strongly recommend the manufacturers of ophthalmology electronic patient record systems (including systems for making and storing ocular biometry measurements), where they fall under the remit of the Medical Device Regulations, undertake an …
Safety Recommendation
Procurement, usability and adoption of ‘smart’ infusion pumps
Medicines and Healthcare products Regulatory Agency (MHRA)
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
National Association of Medical Device Educators and Trainers
Learning Prompt
Placement of nasogastric tubes
The Trust where the reference event happened checked the hospital clinical areas to confirm there were no other areas holding non-CE marked pH testing strips for human gastric aspirate.
Safety Action
Placement of nasogastric tubes
(previously shared in interim bulletin): It is important when transitioning between any types of bedside testing equipment (not just pH strips) the potential for confusion between old and new stock is considered, and the transition managed to reduce that risk …
Safety Observation
Placement of nasogastric tubes
(previously shared in interim bulletin): It is important that organisations are aware that there is not a standard scale/colour scheme across the different manufacturers of CE marked enteral testing strips and they vary in scale (pH of 1-12, 0-6, 2-9 …
Safety Observation
Placement of nasogastric tubes
It is recommended that NHS Supply Chain develops essential specifications to support the clinically-led procurement of devices to include devices to confirm NG tube placement, for example, pH testing strips. The essential specifications should set out a range of factors …
Safety Recommendation
Placement of nasogastric tubes
It is recommended that NHS Supply Chain and the British Standards Institution work together (engaging other system leaders as appropriate, such as the Medicines and Healthcare products Regulatory Agency and NHS England and NHS Improvement), to develop and publish an …
Safety Recommendation
Never events: analysis of HSIB's national investigations
tools and technology: used to undertake the tasks which may vary in usability and functionality
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
It may be beneficial for manufacturers to further standardise product specifications to design out the potential for errors. For example, items such as Y-connectors, extension lines and needle-free connectors often look similar but may have differing specifications.
Safety Observation
Medicine omissions in learning disability secure units
It may be beneficial if user menus on electronic prescribing and medicines administration (ePMA) systems provided clear differences and reasoning for the categories used to record medicines omissions.
Safety Observation
Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment
It may be beneficial to explore the design of a visual alert which prompts healthcare professionals to the increased safety risks associated with in situ haemodialysis catheters and the access to this medical device by staff specifically trained in their …
Safety Observation
Advanced airway management in patients with a known complex disease
Healthcare organisations could improve safety of the management of difficult airways by procuring equipment that has evidence of safety by design and robust user testing and assessment.
Safety Observation
Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports
Original safety recommendation: HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using human factors …
Safety Recommendation
Investigation report: Retained swabs following invasive procedures
A user-centred evaluation of non-technical tools to aid the swab count can improve patient safety by helping national organisations and trusts assess whether their risk of retained swabs is as low as reasonably practicable.
Safety Observation
Investigation report: Retained swabs following invasive procedures
The NHS can improve patient safety by ensuring procurement decisions about swabs are made on a risk-informed basis that incorporates evaluation trials and user-centred design processes in the design, manufacture and testing of products.
Safety Observation
Investigation report: Retained swabs following invasive procedures
Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.
Safety Observation
Investigation report: Retained swabs following invasive procedures
HSSIB recommends that the National Institute for Health and Care Research assesses the priority and feasibility of commissioning research to review the viability of implementing technology that could support reducing the risk of retained swabs. The review should balance patient …
Safety Recommendation
Investigation report: Retained swabs following invasive procedures
HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using human factors expertise and user-centred …
Safety Recommendation
12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — …
Ambulance services can improve patient safety by informing regulators and manufacturers of instances where the use of monitor/defibrillators has impacted on patient safety.
Safety Observation
12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — …
Manufacturers can improve patient safety by identifying the potential design barriers and enablers for ambulance crews entering information about a patient’s age or sex into a monitor/defibrillator. This could inform future device design to increase the likelihood that this information …
Safety Observation
12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — …
Regulatory bodies can improve patient safety by supporting standardisation across manufacturers in how information from ECG traces is displayed.
Safety Observation
12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — …
HSSIB recommends that NHS Supply Chain reviews and amends the procurement framework for monitors/defibrillators to help ambulance services ensure they are fully considering the defibrillation/monitoring and cardiac diagnostic functions of the device when making purchasing decisions, to better reflect how …
Safety Recommendation
Procurement, usability and adoption of ‘smart’ infusion pumps
MEDUSA (UK Injectable Medicine Guide)
Learning Prompt
Placement of nasogastric tubes
It may be beneficial if national organisations including the Medicines and Healthcare products Regulatory Agency, NHS Supply Chain and NHS England and NHS Improvement review arrangements for ensuring all medical device related incidents, Yellow Card reports, or other device safety …
Safety Observation
Weight-based medication errors in children
It would be beneficial if those organisations procuring electronic prescribing and medicines administration systems ascertain whether the product they are procuring meets the definition of a medical device and, if so, whether the manufacturer meets the expected regulatory requirements and …
Safety Observation
Weight-based medication errors in children
It would be beneficial if manufacturers of electronic prescribing and medicines administration systems conducted assessments of their products against the relevant regulation, to identify whether their systems meet the definition of a medical device and, if so, ensure associated regulatory …
Safety Observation
Weight-based medication errors in children
HSIB recommends that the Medicines and Healthcare products Regulatory Agency works with the manufacturers of electronic prescribing and medicines administration systems to provide guidance on their obligations under the Medical Devices Regulations 2002 (as amended).
Safety Recommendation
Medication not given: administration of time critical medication in the emergency department
How does your ePMA system help to alert staff to patients who need time critical medications?
Learning Prompt
Implantation of wrong prostheses during joint replacement surgery
The Department of Health and Social Care expands the remit of the working group consisting of Derby Teaching Hospitals NHS Foundation Trust’s Scan4Safety Programme, the National Joint Registry (NJR), and the Medicines & Healthcare products Regulatory Agency to include alerts …
Safety Recommendation
Implantation of wrong prostheses during joint replacement surgery
NHS Improvement amends the national Prosthesis Verification Standard to incorporate the specific aspects of verification practice developed to mitigate error identified in this investigation.
Safety Recommendation
Insertion of an incorrect intraocular lens
The Department of Health and Social Care commissions a set of standards for the NHS that utilises appropriate technologies to provide digital alerts when incorrect intraocular lens are selected.
Safety Recommendation
Wrong patient details on blood sample
Trusts can optimise the availability, accessibility and usability of appropriate equipment used in blood sampling and labelling (for example: computer terminals, printers, bedside tables, sampling equipment, and that equipment is maintained).
Learning Prompt
Undiagnosed cardiomyopathy in a young person with autism
The Trust where the reference event took place has undertaken to resolve the errors with the clocks on the MRI scanner and anaesthetic monitoring equipment.
Safety Action
Undiagnosed cardiomyopathy in a young person with autism
The recommendation for standardised anaesthetic equipment in the Royal College of Anaesthetists’ ‘Guidelines for the provision of anaesthetic services’ is challenging within the MRI setting given the need for MR-safe/MR-conditional equipment. The Royal College of Anaesthetists has clarified this recommendation …
Safety Action
Residual drugs in intravenous cannulae and extension lines
There is variation between IV devices and associated equipment. Many of these devices appear outwardly similar but, according to manufacturers’ information, have variable specifications relating to the potential for regurgitation.
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
There are issues associated with the design of IV equipment which increase the risk of residual drugs in cannulae and extension lines. There may be opportunities to improve equipment design to design out the potential for errors. The unintended consequences …
Learning Prompt
Recognition of the acutely ill infant
It may be beneficial if NHS England and NHS Improvement’s System-wide Paediatric Observations Tracking (SPOT) Programme considers visual representation of critical information (such as a clinical intervention administered) and the potential impact of these interventions on an infant’s/child’s PEWS.
Safety Observation
Weight-based medication errors in children
It would be beneficial for trusts that have adult and paediatric prescribing supported through the same ePMA system to ensure they have adequately risk assessed the way in which the system supports the calculation of doses to ensure that adult …
Safety Observation
Weight-based medication errors in children
It may be beneficial for trusts to evaluate the use of the free-text fields in electronic prescribing and medicines administration systems and to define their purpose, to ensure they are used in the way intended and used consistently to prevent …
Safety Observation
Risks to medication delivery using ambulatory infusion pumps: design and usability in inpatient settings
Ambulatory infusion pump manufacturers can improve patient safety by considering new technology to develop improved methods of alerting staff to hazardous situations.
Safety Observation
Advanced airway management in patients with a known complex disease
Healthcare providers can improve patient safety by supporting and encouraging anaesthetic staff, anaesthetic assistants and operating department practitioners to become familiar with and experienced in the use of airway rescue equipment and techniques available locally, including videolaryngoscopy.
Safety Observation
Advanced airway management in patients with a known complex disease
HSSIB recommends that the Royal College of Anaesthetists makes changes to its Guidelines for the Provision of Anaesthetic Services (GPAS) requirements for all anaesthetists, to include guidance on: requirements for anaesthetists to have access to videolaryngoscopes in all locations where …
Safety Recommendation
CQC inspection actions(5)
Clatterbridge Hospital
The diagnostic imaging services should ensure that standard MRI safety labels are used on equipment within the MRI unit to identify equipment that is MRI Safe or MRI Not Safe.
Should Do
Private Ultrasound Scan
The service must ensure that equipment used for providing care are safe for use and used in a safe way. This includes regular quality assurance testing of ultrasound scanners by sonographers.
Must Do
St Benedict's Hospice
The service should ensure staff maintain all clear stickers to reflect the last calibrated and tested documentation in line with their process.
Should Do
Cygnet Bury Hudson
The provider should ensure that all equipment used in the delivery of care and treatment is calibrated.
Should Do
Natasha Lucy Clinics
Continue to seek assurances that emergency medical equipment is properly maintained, in line with medical devices regulations.
Should Do
National patient safety alerts(5)
Risk associated with adult breathing circuits lacking a patent exhalation route
Dec 2025
NatPSA/2025/008/NHSPS
Removal of Philips V60 and V60 Plus ventilators from service: risk of unexpected shutdown
May 2023
NatPSA/2023/005/MHRA
NIDEK EyeCee One preloaded Intraocular Lenses: risk of increased intraocular pressure
Feb 2023
NatPSA/2023/003/MHRA
Transition to NRFit connectors for intrathecal and epidural procedures
Jan 2024
NatPSA/2024/002/NHSPS
Use of oxygen cylinders where patients do not have access to medical gas pipeline systems
Jan 2023
NatPSA/2023/001/NHSPS
Health investigations(2)
Independent investigation report into the care and treatment of Yusuf — Rec 3
A functional paediatric pulse oximeter13 was not used when Yusuf attended the GP surgery for his appointment. All practices should have access to age-appropriate equipment, including pulse oximeters, so clinicians can accurately assess sick children when they present.
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Eight
It is recommended that the Trust develops and implements an Objective Structured Clinical Examination (OSCE) framework for the assessment of particular competencies such as observations, medical devices, physical health and medication administration. The further development of Reflective Practice Groups should also be considered.
london
Article 2 learning points(1)
PHSO casework decisions(6)
P-003019 — South Tyneside and Sunderland NHS Foundation Trust
The Trust failed to treat her 'slipped' S-ICD in the emergency department and discharged her without addressing concerns, causing pain and distress until later revision surgery.
NHS in England
Oct 2024
P-003348 — Kettering General Hospital NHS Foundation Trust
Miss G complained her premature son suffered a deep tissue burn from a monitor, alleging staff negligence, failure to inform her, escalate the injury, conduct skin checks, or follow policies.
NHS in England
Feb 2025
P-002622 — University Hospitals Sussex NHS Foundation Trust
Mrs D complained the Trust's ED failed to follow correct diagnostics, misinterpreted a blood test, and ignored her medical history, leading to delayed DVT diagnosis and significant complications.
NHS in England
May 2024
P-003340 — Maidstone and Tunbridge Wells NHS Trust
Mrs D complained staff allowed her husband unsupervised bathroom access without an oxygen extension, failed to give prescribed fluids, antibiotics, or adequate oxygen, and did not inform her of his deteriorating condition.
NHS in England
Partly Upheld
Feb 2025
P-003441 — Leeds Teaching Hospitals NHS Trust
Ms E complained the Trust implanted a non-rechargeable SNS device instead of her chosen rechargeable one, causing discomfort, and she was worried about monitoring and future surgeries.
NHS in England
Mar 2025
P-002353 — A dental practice in the Westminster area
Mr H complained a dental practice provided a badly fitting mouthguard, causing worsening dental problems, including an increased bite, slurred speech, and requiring wisdom teeth removal.
NHS in England
Dec 2023
LGO / SPSO decisions(6)
201508133 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained to us about the care and treatment her son (Mr A) received at Queen Elizabeth University Hospital before his death. Mrs C said that the hospital had not been equipped to meet Mr A's needs. We took independent advice from a nursing adviser. We found that there …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2017
201203665 — Tayside NHS Board
Mrs C complained about the children's waiting arrangements in a hospital accident and emergency department (A&E). She said that when she had to go there with her grandson she was appalled that children waited together with adults and were, therefore, exposed to bad language and inappropriate behaviour. She said that …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2013
201405493 — Ayrshire and Arran NHS Board
Mrs C complained to the board about how her elderly aunt (Miss A) had been cared for in University Hospital Ayr. Mrs C complained to us that Miss A was not given a bed with rails, that hospital staff did not monitor Miss A's movements, and that they did not …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2015
201404381 — Scottish Ambulance Service
Mrs C complained that the Scottish Ambulance Service (the service) did not have the appropriate equipment or vehicle to take her late husband (Mr C) to hospital for a scan. Mr C was terminally ill with cancer and had widespread pain which severely restricted his mobility. Mrs C was also …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2015
201708492 — Lothian NHS Board - Acute Division
Mrs C complained that the board failed to prevent her baby (Baby A) developing hypothermia (the condition of having an abnormally and typically dangerously low body temperature) in the hours after their birth at the Royal Infirmary of Edinburgh. We took independent advice from a midwife. We found that Mrs …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jan 2019
201300375 — Highland NHS Board
Mr C's young daughter (Miss C) suffers from a number of medical conditions and has serious mobility problems. She uses either a wheelchair or a gait trainer, both of which need a lot of space for turning. After a number of years during which the family waited for a suitable …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2013