South Yorkshire (West)

Concerns summary A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.

Concerns summary Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.

Concerns summary Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.

Concerns summary Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.

Concerns summary A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable child placement.

Concerns summary Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance misuse and mental health.

Concerns summary There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.

Concerns summary Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.

Concerns summary A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.

Concerns summary Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.

Concerns summary The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately used to record incidents or monitor injury progression.

Concerns summary Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and escalation routes for mental health concerns, creating a risk of future deaths.

Concerns summary A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.

Concerns summary A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.

Concerns summary Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures for investigating and assessing risks following catastrophic incidents in social housing.

Concerns summary Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of positional asphyxia in detainees. There's also no mandatory refresher training for constant observations.

Concerns summary There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process for patients with hydrocephalus shunts, risking fatal outcomes.

Concerns summary An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.

Concerns summary A crucial individualised care plan was difficult to find and not used during the patient's admission, despite being flagged, risking inadequate care.

Concerns summary The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.

Concerns summary An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.

Concerns summary A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.

Concerns summary Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency call responses.

Concerns summary Failures in discharge planning, inconsistent medical note review, outdated risk assessments, and poor record-keeping without audit systems led to fragmented care and a lack of understanding of the patient's condition.

Concerns summary The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack of required protective equipment could lead to future deaths.