Coventry

Concerns summary Concerns include poor patient awareness and clinical follow-up for salbutamol overuse, prolonged ambulance handover delays impacting emergency availability, and unclear NHS Pathways triage questions.

Concerns summary Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential conflicts of interest when staff recognise patients outside of personal relationships.

Concerns summary Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent methods to identify 'fronting' and effectively communicate telematics-related safety.

Concerns summary The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety hazards.

Concerns summary Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.

Concerns summary Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have not been implemented in a psychiatric unit for over 42 months.

Concerns summary Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney transplant patients.

Concerns summary Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.

Concerns summary Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.

Concerns summary Widespread bin lorries contain significant design flaws, particularly in the automatic bin lift system, creating a foreseeable risk of workers being inadvertently lifted into the hopper and causing death, with slow and optional safety updates.

Concerns summary Care home staff lacked ingrained emergency training, leading to delayed and suboptimal responses to a choking incident and improper use of emergency services.

Concerns summary Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.

Concerns summary Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in patient discussion and transfer.

Concerns summary Street lighting was unlit due to an underground cabling fault, likely from a previous collision. This lack of illumination along the road created a dangerous hazard for road users.

Concerns summary A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying and escalating health and safety issues.

Concerns summary Policies for high-risk pregnancies were not followed, leading to a failure to consider elective Caesarean Section. There's inadequate training and assessment for junior and locum doctors on identifying serious risk factors.

Concerns summary Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing exposure to home birth practice. This raises concerns about maintaining competency in all areas of midwifery practice.

Concerns summary The legal framework concerning Nitrous Oxide needs review due to increasing use by young persons and its association with deaths.

Concerns summary Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College guidance for returning ED patients and investigating neurological findings like subarachnoid haemorrhage, with learning not effectively embedded.

Concerns summary Concerns include the failure to appoint a Care Co-ordinator and significant, ongoing staffing shortages within mental health services in the North Warwickshire area.

Concerns summary Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.

Concerns summary The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.

Concerns summary The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.

Concerns summary Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.

Concerns summary The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing a risk to their safety.