Lancashire and Blackburn with Darwen

Concerns summary An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.

Concerns summary HMP Garth has a critical lack of psychologist resources for prisoners, with severe staffing gaps and extensive waiting lists for mental health support.

Concerns summary Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, with staff unaware of required frequency.

Concerns summary Inaccurate fluid balance charting, unrecorded seizure activity, and a lack of procedures for ED readmission after recent surgery, including insufficient triage training, posed significant risks.

Concerns summary Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of regional mutual aid.

Concerns summary The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk from drivers with compromised abilities.

Concerns summary The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses through deception, creating a significant road safety risk.

Concerns summary The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance response for at-risk patients.

Concerns summary The Trust suffers from a deep-seated lack of candour, transparency, and deficient clinical governance, resulting in a failure to learn from past incidents, unreliable data, and inadequate reporting of serious harms.

Concerns summary Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.

Concerns summary There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.

Concerns summary In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.

Concerns summary A highly inappropriate surgical technique for suprapubic catheter insertion in a complex patient led to bowel perforation, compounded by inadequate use of imaging guidance and specialist consultation despite known risks.

Concerns summary Inadequate nursing records and handovers, coupled with doctors' poor task prioritisation, resulted in failures to request timely medical reviews and urgent clinical assistance for a patient with a significant bleed.

Concerns summary There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is unavailable when needed.

Concerns summary Highway operatives lack specific training to identify road defects hazardous to cyclists. Additionally, a road's natural geological movement causes defects that current inspections may not adequately identify, posing risks to all road users.

Concerns summary The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.

Concerns summary The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.

Concerns summary Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic problem.

Concerns summary The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.

Concerns summary An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.

Concerns summary Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.

Concerns summary Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, posing a risk of misuse.

Concerns summary Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.

Concerns summary The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.