Leicester City and South Leicestershire

Concerns summary A statutory requirement to provide beds for mentally disordered patients in special urgency cases is being ignored, leading to a lack of identifiable beds for high-need individuals.

Concerns summary Critical discharge instructions for anti-embolism stockings were not communicated, leading to the patient's unawareness of their necessity. This highlighted a failure in staff training and discharge documentation protocols.

Concerns summary On-call psychiatry doctors lacked remote access to medical records, family members were not routinely involved in care planning, and frontline staff received insufficient self-harm training.

Concerns summary A lack of mandatory, compatible anti-collision systems and the absence of Air Traffic Control at a busy airfield created significant collision risks, exacerbated by human eye limitations in adverse weather.

Concerns summary There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, with the crisis team unable to fill this gap.

Concerns summary Ineffective referral and incident reporting systems, poor communication with families, and significant delays in providing first aid after patient falls highlight systemic failures in care and oversight.

Concerns summary A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.

Concerns summary Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading to a patient's INR increasing dangerously without intervention.

Concerns summary Next of kin were not involved in a significant decision to change the patient's GP, and there was no documented rationale, consent, or capacity assessment for this transfer of care.

Concerns summary Hospital discharge letters contained significant inaccuracies and omissions, often completed by junior doctors who hadn't seen the patient, risking serious care mistakes for vulnerable patients.

Concerns summary A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme Approach and NICE guidelines were not followed.

Concerns summary The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised practice, poses a significant risk to patient safety.

Concerns summary ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.

Concerns summary Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment design posed a release risk.

Concerns summary Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.

Concerns summary Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.

Concerns summary E45 cream, a highly flammable paraffin-based product, lacked fire hazard warnings on its packaging and prescription, leading to a dangerous lack of awareness among carers and the deceased.

Concerns summary A lift lacked signs or auditory warnings for its rear doors, which were indistinguishable from the interior, posing a significant safety risk to passengers unaware of their opening mechanism.

Concerns summary Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.

Concerns summary Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.

Concerns summary Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.

Concerns summary Community healthcare providers failed to use a sepsis screening tool or adopt the national sepsis clinical toolkit, leading to missed diagnosis opportunities and delayed emergency admission.

Concerns summary Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was unclear.

Concerns summary Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke as an immediate emergency, risking critical treatment windows.

Concerns summary Highway safety is compromised by overgrown hedgerows obscuring junction visibility, a lack of warning signage, and an uncurtailed national speed limit, creating collision risks.