Nottingham City and Nottinghamshire

Concerns summary The easy online availability of lethal Sodium Nitrite, combined with suppliers' unawareness of its misuse and slow removal of suicide-related online guidance, facilitates self-harm.

Concerns summary A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.

Concerns summary The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.

Concerns summary The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.

Concerns summary Persistent staff non-compliance with eating and drinking guidelines, coupled with management's failure to understand and monitor these issues, and inadequate provision of funded support, compromised patient care.

Concerns summary Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely ill babies in ED compromise patient safety.

Concerns summary Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover documentation compromised care in the Emergency Department.

Concerns summary The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack of thorough investigation and learning.

Concerns summary The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.

Concerns summary Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.

Concerns summary Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.

Concerns summary Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.

Concerns summary The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.

Concerns summary Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to include all staff in notifications for highly transmissible cases.

Concerns summary There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.

Concerns summary Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action to minimize exposure.

Concerns summary Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious patients and deviated from national guidelines, alongside a lack of guidance for Psychogenic Polydipsia.

Concerns summary Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving care home also lacked the authority to refuse referrals despite insufficient information.

Concerns summary Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited staff awareness of ligature risks compromised patient safety.

Concerns summary Emergency response systems and staff training are inadequate, causing significant delays in obtaining monitoring, doctor attendance, and ambulance calls for patients with critical breathing concerns.

Concerns summary A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for defibrillator status is also lacking.

Concerns summary Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.

Concerns summary Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.

Concerns summary Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also delayed crucial organizational learning.

Concerns summary Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.