Birmingham and Solihull

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 Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.

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

Concerns summary The absence of a clear regional protocol for sickle cell disease management led to staff lacking knowledge of crisis symptoms and necessary treatment, compounded by funding issues.

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 GP practice lacked a system for promptly reviewing abnormal blood test results and initiating patient follow-up, causing critical delays in treatment.

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 This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, and pedestrian crossing measures have not been implemented, posing ongoing safety risks.

Concerns summary Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.

Concerns summary Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing best practices or lessons learned across units to minimise this risk.

Concerns summary A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory Care Unit unnoticed, subsequently taking his own life.

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.