Rutland and North Leicestershire

Concerns summary Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for wing office fault reporting.

Concerns summary There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.

Concerns summary National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a wider safety issue.

Concerns summary High-risk medical equipment, like an armchair belt, is sold online without warnings or professional guidance, exposing vulnerable users to serious risks such as strangulation.

Concerns summary Concerns arise from the inability to obtain medical records or information from the Turkish hospital regarding fitness for surgery, alongside inadequate post-operative care and communication for a patient undergoing cosmetic surgery abroad.

Concerns summary Industry-standard training for operating mobile elevated work platforms (MEWPs) lacks practical rescue-at-height drills, posing a significant risk in time-sensitive emergency scenarios.

Concerns summary Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of risk assessment decisions, while a nurse failed to review medical records.

Concerns summary Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a significant overdose risk.

Concerns summary DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of existing support tools.

Concerns summary Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services attend.

Concerns summary Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an incident.

Concerns summary Unsafe loading shovel work methods and a lack of clear guidance and enforcement for drivers to stay in cabs put workers at risk. Training for risk assessment and health and safety awareness was inadequate.

Concerns summary Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.

Concerns summary A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.

Concerns summary A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.

Concerns summary Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.