South Yorkshire (West)

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 information sharing, inaccurate incident location, and deficient risk assessments for highway hazards (including flooding and tree growth impacting lighting) contributed to ongoing road safety concerns.

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 Insufficient and undocumented training for nurses on portable oxygen cylinder use, following task reassignment, resulted in a critical error during patient transfer.

Concerns summary Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.

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 The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health resources in the area.

Concerns summary Gantry safety barriers were too low, lacked an intermediate crossbar and toe-plate, and fall protection at the access ladder was inadequate, creating significant fall risks.

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 Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.

Concerns summary Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during meal breaks.

Concerns summary A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient encouragement for insurers to deny cover to establishments selling 'legal highs' linked to mental health issues.

Concerns summary Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.

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 A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication prescriptions.

Concerns summary The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly as the limit increases on approach, contributing to repeated incidents.

Concerns summary Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police when she disappeared, were significant concerns.

Concerns summary Surgical equipment design flaws, including the lack of a brightly coloured detachable cap on a bulb syringe, led to a retained tip. A national safety recommendation for such caps was ignored, and no cap counting procedure exists.

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.