Leicester City and South Leicestershire

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

Concerns summary A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.

Concerns summary Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.

Concerns summary Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.

Concerns summary The road junction at Upper Kings Street and Regent Road has significant safety concerns due to poor visibility, inadequate filter lanes, heavy traffic, and road contour, posing risks to cyclists.

Concerns summary Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost records.

Concerns summary An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, up-to-date system.

Concerns summary Inconsistent patient assessment approaches by clinicians and a lack of nationally agreed standard assessment forms hinder effective communication and care continuity for mental health patients across different trusts.

Concerns summary Discharge planning was inappropriate due to insufficient staff training on bed rails. There were also policy conflicts between hospital and community services, and inadequate coordination for equipment provision and follow-up.

Concerns summary Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.

Concerns summary Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.

Concerns summary Outdated glass in older rented properties poses a significant safety risk as there is no legal requirement for landlords to proactively check or replace it unless it breaks or during refurbishment.

Concerns summary The Trust submitted an inaccurate and flawed investigation report with incorrect root causes, failing to identify actual service difficulties and delaying communication of these issues.