Berkshire

Concerns summary 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.

Concerns summary There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.

Concerns summary A significant majority of obstetricians have not received crucial specific training related to this incident, raising concerns about the trust's commitment to learning and patient safety.

Concerns summary Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are not repositioned as required.

Concerns summary The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon also remain unaddressed.

Concerns summary A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks overlooking critical objective indicators.

Concerns summary The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged immobility.

Concerns summary Careline operator training and call protocols were inadequate to identify severe injuries in callers with cognitive impairments, specifically failing to elicit critical information despite the user's distress.

Concerns summary The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.

Concerns summary Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed PFD reports.

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

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

Concerns summary There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.

Concerns summary Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in patient discharge from hospitals.

Concerns summary Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due to financial and compatibility issues.

Concerns summary The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and ensuring follow-through on study suspensions, and staff underestimated mental health risks.

Concerns summary Pharmacists lacked guidance for dispensing medication to cognitively impaired patients, leading to identical dosset boxes for cohabiting individuals, which directly contributed to medication mix-ups and posed a safety risk.

Concerns summary Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking patient safety.

Concerns summary Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the 24-hour period only upon ward admission, despite long patient waits.

Concerns summary Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular disease or use of risk-based stratification, omitting vital health indicators.

Concerns summary Clinicians and practitioners involved in mental health inpatient discharge lack adequate training in the discharge process, particularly concerning complex issues arising from out-of-area admissions.

Concerns summary GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the lack of a formal policy for referral thresholds risks missed cancer diagnoses.

Concerns summary Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or clear channels for raising concerns. Local authority support also lacks formal policy.

Concerns summary Extendable trailers' sideguards, compliant only at their shortest length, leave dangerous gaps when extended. This regulatory loophole creates an equivalent hazard to unprotected road users as fixed trailers.

Concerns summary The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.