South Yorkshire (West)

Concerns summary A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.

Concerns summary Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes placement in adult crisis units and unsupervised supported living post-assessment.

Concerns summary The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or specific protocol for critical non-cancerous results.

Concerns summary Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.

Concerns summary A 'Drive Clean System' in the vehicle, which encourages smooth driving, may have discouraged the driver from making necessary evasive steering movements, potentially contributing to the fatality. The system's influence on driver response requires review.

Concerns summary A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.

Concerns summary Water pooling on a busy road and verges that could propel cars over safety barriers create hazardous driving conditions, despite the drainage being considered operative.

Concerns summary Carers lacked training and clear guidance on how to manage unusual and difficult situations, specifically regarding an overheating client from a heater, leading to a fatal outcome.

Concerns summary The hotel allowed smoking near the canal without adequate barriers to prevent falls, and the canal itself lacked any means of escape for individuals who fell in.

Concerns summary Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on managing risks associated with alcohol withdrawal.

Concerns summary Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.

Concerns summary Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.