Coventry

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 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 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 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 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 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.

Concerns summary The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.

Concerns summary Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.

Concerns summary Repeated misdiagnoses occurred at the hospital, despite clear GP instructions, due to systemic failures in accessing electronic patient records and slow scanning of notes.

Concerns summary The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.

Concerns summary A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the ambulance.

Concerns summary A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.

Concerns summary Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to missed opportunities for early recognition, de-escalation, and appropriate management.

Concerns summary There was a severe 7-month delay in pothole repair, exacerbated by the County Council's lack of a system to track works orders or audit completion and quality, leading to the wrong repair being performed.

Concerns summary Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness during subsequent assessments.