Nottingham City and Nottinghamshire

Concerns summary Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable individuals without adequate human rights safeguards.

Concerns summary Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.

Concerns summary The medical group had multiple systemic failures, including unsafe patient triage and home visit procedures, insufficient clinical capacity, poor documentation, and a lack of processes for reviewing significant events to learn from them.

Concerns summary An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety netting, and presented trip hazards due to an uneven surface, risking falls for staff and the public.

Concerns summary National ambulance response times for category 2 calls, including potential cardiac events, are too slow, and local attempts to mitigate this through triage are hampered by insufficient resources.

Concerns summary NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.

Concerns summary Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, and medication errors highlighted a concerning culture of acceptance.

Concerns summary The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks to patients.

Concerns summary Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.

Concerns summary Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.

Concerns summary The railway crossing lacked essential telephones and Network Rail contact information, posing a risk of repeat incidents due to inadequate emergency communication at the site.

Concerns summary Nursing home staff were unaware of and failed to adhere to SALT recommendations for supervision and diet, resulting in missed re-referral opportunities and inadequate choking risk assessments.

Concerns summary Numerous failures in nursing home care included not seeking specialist advice, missing appointments, inadequate record-keeping, and poor recognition/response to deteriorating patient condition and insulin refusal.

Concerns summary A complex road junction suffers from poor visibility due to an incline and queuing right-turning vehicles. Unclear right-of-way indications, inadequate signage, and a problematic solid white line create significant safety risks.

Concerns summary Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.

Concerns summary The Crisis Team failed to provide consistent care, maintain accurate records, or promptly escalate concerns, leading to delays in crucial decision-making regarding the patient's management and potential hospitalisation.

Concerns summary Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.

Concerns summary A doctor engaged in a pattern of telephone diagnoses, failed to accurately record consultations, and falsely documented examinations. Concerns extend beyond poor record-keeping, questioning the doctor's fitness to practice and highlighting wider public safety implications of such practices.

Concerns summary There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.

Concerns summary The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for patients.

Concerns summary The collision scene is hazardous due to its tendency to accumulate standing water during rainfall and a gap in the vehicle restraint barrier, which allows unimpeded traffic access.

Concerns summary A lack of consultant paediatrician review, inadequate sepsis training, poor handover protocols, and insufficient paediatric staffing levels put sick children at serious risk.

Concerns summary There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.

Concerns summary Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to precarious patient care and significant delays in treatment.

Concerns summary Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.