Cheshire

Concerns summary A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.

Concerns summary A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, increasing risk of death.

Concerns summary A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.

Concerns summary Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.

Concerns summary Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.

Concerns summary GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.

Concerns summary The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.

Concerns summary The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.

Concerns summary Inadequate nursing record-keeping and a failure to escalate a patient's significant deterioration to a doctor led to an unsafe discharge in very poor physical condition.

Concerns summary HSE guidance and support materials lack clear images and instructions for drivers on safely loading and unloading overhanging bales on slopes, particularly concerning widthways loading and centre of gravity risks.

Concerns summary The absence of a legal requirement for smoke alarms in non-hire narrowboats, unlike carbon monoxide alarms, increases the risk of fire fatalities from smoke inhalation and burns.

Concerns summary The absence of lifeguards, warning signs, or flags on a rough beach during tourist season created unsafe swimming conditions, despite high public usage.

Concerns summary The HIAB crane lacked an audible warning during operation and a two-handed remote design, increasing the risk of accidental activation.

Concerns summary The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and hindering the ability to establish facts and implement preventative measures.

Concerns summary Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent with expected standards and poses a risk.

Concerns summary A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to wait in A&E.

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 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 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.