Nottingham City and Nottinghamshire

Concerns summary Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.

Concerns summary The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, and transfer criteria between services are unclear.

Concerns summary The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.

Concerns summary A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.

Concerns summary Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its investigation and referral.

Concerns summary There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, causing confusion over referral responsibilities.

Concerns summary There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the specialist Personality Disorder Hub was disbanded, reducing expert care.

Concerns summary The Emergency Department failed to review an undiagnosed aortic dissection, and a middle-grade doctor did not escalate a changing clinical picture, indicating ineffective training on atypical presentations.

Concerns summary Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff on paediatric guidelines.

Concerns summary Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.

Concerns summary Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.

Concerns summary A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for vulnerable individuals.

Concerns summary The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team support during procedures.

Concerns summary Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for vulnerable individuals.

Concerns summary Widespread non-compliance with daily skin inspections, inadequate care plan updates, and delays in pressure ulcer management, compounded by poor record-keeping, led to a patient's deterioration.

Concerns summary The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This self-reporting is inadequate and poses a risk of future road deaths.

Concerns summary No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.

Concerns summary Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic safety protocols.

Concerns summary There is no requirement for electric scooter riders to wear helmets, increasing the risk of fatal head injuries in collisions due to their vulnerability on the road.

Concerns summary Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access to healthcare support compared to those in custody.

Concerns summary Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and detecting criminal financial enterprises.

Concerns summary There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.

Concerns summary Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.

Concerns summary Concerns were raised about persistent poor record keeping and inadequate communication between professionals within the Trust and with patients.

Concerns summary Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.