Coventry

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 Failures included ineffective oversight of duty worker decisions, poor waiting list management, unclear processes for patient non-attendance, and inadequate family involvement in care planning.

Concerns summary A dangerous diversion road with a history of fatalities lacked crucial 'single carriageway' warning signs, and sat navs directed drivers into the wrong lane, posing significant road safety risks.

Concerns summary Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.

Concerns summary A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.

Concerns summary There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal head injuries.

Concerns summary Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for a determined casualty reduction scheme.

Concerns summary Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.

Concerns summary Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct proper in-room checks, relying instead on distant sightings.

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.

Concerns summary Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were inadequate.

Concerns summary Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.

Concerns summary Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his death.

Concerns summary Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.

Concerns summary Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.

Concerns summary Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.

Concerns summary The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.

Concerns summary A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety risks.