Birmingham and Solihull

Concerns summary Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.

Concerns summary Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.

Concerns summary A general practitioner failed to conduct a physical examination during a home visit for a post-surgery patient complaining of pain and ill health.

Concerns summary There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.

Concerns summary There is a national lack of understanding and training regarding acute behavioural disturbance and the risks of prolonged restraint. Additionally, specialized mental health crisis teams and updated patient conveying policies are not nationally implemented.

Concerns summary Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.

Concerns summary Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.

Concerns summary The unrestricted sale of large helium gas canisters without safety controls, coupled with readily available online suicide guidance, contributes to a concerning rise in helium-related suicides.

Concerns summary A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.

Concerns summary The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist consultations, despite available national and regional pathways.

Concerns summary Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.

Concerns summary Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.