South Yorkshire (West)

Concerns summary Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.

Concerns summary Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.

Concerns summary There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.

Concerns summary A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both the armed forces and the family was inadequate, hindering effective risk sharing and support.

Concerns summary The diagnostic process lacked professional curiosity and critical review of patient disclosures, leading to unverified information influencing care. Crucial information sharing with family was inadequate, and self-harm incidents lacked debriefs to inform future risk assessments.

Concerns summary Delays occurred in both accepting transfer to hospital and inserting a necessary NG tube. There was a lack of clear policies and procedures for transferring patients under section, including required documentation.

Concerns summary The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.

Concerns summary Parents were not informed of a critical consultant plan for a central line review. Concerns also include a lack of consideration for national form suitability and how regional support is accessed for highly vulnerable babies.

Concerns summary Senior clinicians and staff displayed a grave lack of understanding and application of the Mental Capacity Act, with inadequate training leading to failures in best interests decision-making and patient/family involvement.

Concerns summary The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.

Concerns summary Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly identify stationary vehicles, necessitating better driver awareness and a wider public inquiry beyond inquest limitations.

Concerns summary Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.

Concerns summary Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.

Concerns summary Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.

Concerns summary Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a lack of thickener for fluids, contributed to patient neglect.

Concerns summary High resource pressure resulted in a missed two-hour review of an emergency call, preventing re-categorisation and potentially impacting outcomes in future cases.

Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Concerns summary Care centres fail to prioritise dental hygiene and services, leading to potentially worsened conditions and lacking policies for managing missed appointments or identifying dental care needs.

Concerns summary A critical gap exists in urgent mental health services for 16 and 17-year-olds in Sheffield, with necessary additional resources for CAMHS lacking guaranteed funding.

Concerns summary Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.

Concerns summary Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant delays in diagnosis.

Concerns summary The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.

Concerns summary The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for high injury potential, and requires a review of its methodology for future events.

Concerns summary An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed to safety concerns.

Concerns summary Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them to miss a red light prohibiting them from crossing the main road.