Greater Lincolnshire

Concerns summary Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also inadequately categorises ABD cases.

Concerns summary Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and disparate, leading to a failure to act on these critical safety concerns.

Concerns summary An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying treatment and highlighting a guidance gap.

Concerns summary Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for highway safety improvements.

Concerns summary Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.

Concerns summary Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.

Concerns summary A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.

Concerns summary Inadequate falls prevention policy, unlocked doors, unlit common areas, missing signage, and insufficient nightly observations created an unsafe environment.

Concerns summary The "give way" signage at a junction with restricted visibility may be insufficient, as drivers must stop to ensure safety, raising concerns that a "stop" command would be safer.

Concerns summary A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.

Concerns summary Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.

Concerns summary Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide attempts. A recommended face-to-face assessment was replaced by a telephone call, leading to case closure.

Concerns summary Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and training review.

Concerns summary Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.

Concerns summary A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral haemorrhage.

Concerns summary The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.

Concerns summary The staircase at a holiday rental may not have met safety regulation standards for width, depth, and handrails at the time of a fatal fall, indicating a potential ongoing risk.

Concerns summary Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There is a need for improved training on mental welfare procedures.

Concerns summary An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing the driver's view of a cyclist.

Concerns summary The full implementation of a nine-point action plan from December 2019 to prevent further deaths, including specific dates, needs to be confirmed and any partial implementation justified.

Concerns summary Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.

Concerns summary Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.

Concerns summary Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.

Concerns summary Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.

Concerns summary Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, or temporary speed limits, creates a high-risk environment for students.