Derby and Derbyshire

Concerns summary The tyre barrier failed to absorb sufficient impact energy, and available energy-dissipating protection was not utilised. Furthermore, wet track conditions and racer error were not adequately considered in safety assessments.

Concerns summary A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, risks patients missing crucial medication information.

Concerns summary The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded by false reassurance from NEWS scores, led to missed opportunities for earlier treatment.

Concerns summary There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, compounded by ongoing recruitment difficulties.

Concerns summary Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.

Concerns summary Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific alcohol misuse guidance from the Rugby Football Union for volunteer-run organizations.

Concerns summary The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of a scroll feature, and inability to prominently flag out-of-range values.

Concerns summary The Trust lacks robust and timely processes for updating clinical policies, incorporating national guidance, and obtaining essential equipment, risking similarly avoidable deaths.

Concerns summary A lack of clear, detailed handover and transfer documents between hospitals meant critical patient information was not exchanged, preventing appropriate enhanced care and falls prevention.

Concerns summary There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.

Concerns summary The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.

Concerns summary Lack of mandatory standards and inspection for river ford depth gauges, combined with poor inter-agency information sharing on previous incidents, creates significant safety risks, especially with increasing severe rainfall.

Concerns summary GP practice administrative staff failed to relay suicidal ideation to the GP, who then did not perform an adequate mental health risk assessment; internal reviews also failed to identify these critical errors.

Concerns summary England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.

Concerns summary New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.

Concerns summary Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.

Concerns summary Fragmented patient information across multiple systems, inconsistent head injury policies, inadequate anticoagulation guidelines, and insufficient falls form guidance created significant safety risks.

Concerns summary Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.

Concerns summary Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and insufficient consideration for pilot size/weight in system configuration pose safety risks.

Concerns summary The nursing home lacked formal policies for crucial areas including resident observation, food storage security, managing dementia residents, and caring for patients on liquid diets.

Concerns summary Resourcing issues pose a risk of future deaths if urgent patient transfers remain unavailable for acutely ill patients.

Concerns summary The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the data shared, risking missed critical details.

Concerns summary Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.

Concerns summary The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.

Concerns summary Insufficient and easily obscured advanced warning signage for a dangerous junction with a history of serious incidents poses an ongoing risk, despite awareness of the need for improvements.