Derby and Derbyshire

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 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 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 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 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 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 A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.

Concerns summary The care home lacked clear, robust policies for falls prevention and management, which were also not consistently understood or implemented by staff. This indicates a systemic failure in falls safety.

Concerns summary The internal investigation into the death was perfunctory, lacked robust inquiry, missed key interviews, and contained factual inaccuracies, risking future patient harm.

Concerns summary A critical misunderstanding existed between mental health teams regarding care coordination and adherence to the Care Programme Approach (CPA), leading to confusion about who was responsible for the patient's ongoing care.

Concerns summary A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.

Concerns summary The Red Bag scheme, designed to transfer vital care home patient information to hospitals, is underutilized and hospital staff are unaware of its purpose, leading to critical care plans not being accessed.

Concerns summary Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.