Birmingham and Solihull

Concerns summary There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective use during cardiac arrest.

Concerns summary Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.

Concerns summary Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.

Concerns summary The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.

Concerns summary After a patient collapsed in a GP surgery, there was inadequate ventilation, no suction, and no oxygen provided for 8 minutes, raising concerns about resuscitation expertise and equipment in GP practices.

Concerns summary Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.

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 Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.

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 previously unrecognised risk of air entering the vascular system during a cardiac procedure with conscious sedation was identified, highlighting a critical lack of awareness and necessary safeguards across cardiac centres.

Concerns summary The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.

Concerns summary There are serious deficiencies in the medical assessment process for drivers, including insufficient investigation of health conditions, leading to inadequately assessed individuals being permitted to drive.

Concerns summary The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.

Concerns summary Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.

Concerns summary Quad bike riders on public roads are not required to wear crash helmets or possess additional driving qualifications, posing significant safety risks due to insufficient regulations.

Concerns summary Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, lack of overnight monitoring, and poor external security measures allow widespread drug use and concealment.

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 Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.

Concerns summary Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.

Concerns summary A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.

Concerns summary The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.

Concerns summary The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate leadership and medical cover. RMN training also failed to cover pressure sores sufficiently.

Concerns summary A new tracker system failed to identify static soldiers, commanders lacked awareness and training on critical heat illness guidance, and risk assessment staff were untrained. A disjointed reporting system also impedes accurate heat illness data.