Cheshire

Concerns summary The absence of residential substance misuse treatment facilities for children under 18 in England places them at increased risk of relapse and overdose by requiring parents to manage complex detoxification at home.

Concerns summary A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.

Concerns summary DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.

Concerns summary Guidance for abdominal aortic aneurysm and acute pancreatitis lacks caution about their diagnostic overlap, risking fatal misidentification, even when imaging is advised for diagnostic uncertainty.

Concerns summary Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a previous coroner's intervention.

Concerns summary An online book providing explicit, step-by-step suicide instructions, including methods to avoid detection, is readily accessible with inadequate age verification, posing a significant risk to vulnerable individuals.

Concerns summary GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.

Concerns summary The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.

Concerns summary The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.

Concerns summary Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.

Concerns summary There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk of further self-inflicted deaths.

Concerns summary Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was no investigation into the operating table death, and embalming and medical reporting were inadequate.

Concerns summary Repeated "rollaway" incidents with vehicles indicate a serious ongoing safety risk, suggesting that regular and periodic training for drivers on coupling and uncoupling procedures is inadequate.

Concerns summary An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, affecting risk assessment and recall procedures upon release.

Concerns summary Ambulance service demand critically outstrips supply, leading to excessively long response times across all categories due to wider resource shortages in healthcare and social care.

Concerns summary The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.

Concerns summary The lack of lighting on a section of the motorway is an ongoing risk, having contributed to collisions, and its safety implications were not reassessed during the 'smart motorway' conversion.

Concerns summary A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.

Concerns summary The A34 bypass at Melrose Way Bend is dangerous due to the absence of a continuous white line, allowing unsafe overtaking in dark conditions and posing a risk to lives.

Concerns summary The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.

Concerns summary The A34 bypass (Melrose Way Bend) is dangerous due to the lack of a continuous white line, allowing unsafe overtaking on a dark stretch of road.

Concerns summary The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.

Concerns summary The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.

Concerns summary Safety concerns include hazardous junction configuration, insufficient street lighting, vegetation obstructing visibility, and an inappropriate speed limit.

Concerns summary A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence means workers lack essential guidance on risks and safety strategies.