Nottingham City and Nottinghamshire

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 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.

Concerns summary There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance auditing, risking deaths from unrecognized deterioration.

Concerns summary Repeated instances of placentas being interfered with or disposed of prematurely in early neonatal deaths hinder paediatric post-mortem examinations, limiting coronial findings, learning, and parental information.

Concerns summary Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.

Concerns summary Inexperienced staff conducting assessments for vulnerable individuals with homelessness and substance misuse issues lead to inaccurate plans, and Care Act re-referrals for changing accommodation are resisted.

Concerns summary The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious local systemic issue.

Concerns summary The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.

Concerns summary The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.

Concerns summary Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic failures.