Leicester City and South Leicestershire

Concerns summary The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future deaths where still implemented.

Concerns summary The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing data from aircraft manufacturers to suppliers for assessing critical components.

Concerns summary Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic issue risks future deaths.

Concerns summary There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.

Concerns summary The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.

Concerns summary Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively gather crucial information from private psychiatrists for risk assessment, hindering comprehensive care.

Concerns summary Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.

Concerns summary A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.

Concerns summary Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care needs beyond emergencies.

Concerns summary Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to incorrect medication understanding and poor record review.

Concerns summary Inadequate player protection tools and a flawed algorithm failed to identify and intervene with a problem gambler. The operator's reliance on minimal regulatory standards, rather than best practice, exacerbated risks.

Concerns summary Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.

Concerns summary Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.

Concerns summary Emergency response protocols dangerously delay life-saving equipment by requiring assessment before retrieval. Additionally, observation policies were inconsistently applied and new policies are not aligned with recording forms.

Concerns summary Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.

Concerns summary The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring for vulnerable residents with complex mental health and substance misuse needs.

Concerns summary Inconsistent district nurse assignments, lack of photographic wound documentation, and inability to access electronic patient records at home hindered proper assessment of changing patient conditions.

Concerns summary Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing platforms risk over-prescription, drug interactions, and patient harm.

Concerns summary National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across trusts.

Concerns summary Midwives are potentially deployed to community roles too soon after qualifying, lacking adequate experience, which is a concern for patient safety across the nation.

Concerns summary The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.

Concerns summary A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, causing distress and inadequate support prior to discharge.

Concerns summary The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.

Concerns summary The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and potential rescuers' lives.

Concerns summary Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family contact and local support.