Birmingham and Solihull

Concerns summary Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, and the manufacturer has not provided a solution.

Concerns summary A systemic failure in a care home led to inadequate and unrecorded skin inspections for a frail resident over multiple days, posing a significant risk to vulnerable patients.

Concerns summary The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.

Concerns summary A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant risk if alarms are unusable during emergencies.

Concerns summary Inadequate training and lack of competency assessment for junior doctors on central line blood draws, compounded by poor handover between wards, create inherent safety risks.

Concerns summary The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the falls risk assessment, and provided misleading observation records, indicating systemic safety failures.

Concerns summary Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.

Concerns summary A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a risk of further missed appointments.

Concerns summary Standard lorry mirrors provide distorted, inadequate vision and are prone to dirt, creating an avoidable blind spot risk for drivers and posing a danger to other road users.

Concerns summary The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.

Concerns summary Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.

Concerns summary The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, fluid management, and post-operative care, endangering patients.

Concerns summary There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments are inadequate for both pedestrians and staff on the track.

Concerns summary There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant risk of collapse or death during military exercise.

Concerns summary Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.

Concerns summary A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or users, about this safety hazard.

Concerns summary The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.

Concerns summary The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.

Concerns summary The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with stationary vehicles, especially given high speeds and limited escape options on elevated stretches.

Concerns summary Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to unsuitable placements and a lack of post-admission care plans and risk assessments.

Concerns summary A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself is complex and lacks clear protocols for individual risk and new fitness tests.

Concerns summary Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge areas and confusing signage on dynamic hard shoulders, increasing the risk of fatal collisions.

Concerns summary A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked resources for adequate patient assessment and monitoring.

Concerns summary Systemic delays in mental health act assessments due to inter-agency confusion and resource shortages led to critical information being missed and the incorrect legal framework being applied. Walsall MBC also failed to investigate these failings.

Concerns summary Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.