West London

Concerns summary Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.

Concerns summary Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.

Concerns summary A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.

Concerns summary Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.

Concerns summary Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper training oversight.

Concerns summary There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants at risk of suffocation.

Concerns summary A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of accidents. Redesign plans are uncertain and significantly delayed.

Concerns summary Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and an inappropriate "closed" visit denied a detainee physical contact and private conversation with family.

Concerns summary Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient for this accelerated disease, risking future deaths.

Concerns summary The existing policy for COVID-19 testing prior to cardiac surgery requires review to ensure patient safety and prevent future deaths.

Concerns summary Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.

Concerns summary Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.

Concerns summary Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT process.

Concerns summary Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures and oversight.

Concerns summary An elderly, frail resident sustained a fatal head injury due to a fall while mobilising, caused by an inexperienced carer who lacked sufficient training and supervision to provide safe assistance.

Concerns summary The Metropolitan Police's Driver & Vehicle Policy lacks sufficient focus on other road users' safety and contains ambiguous guidelines on the "silent approach" and use of warning equipment.

Concerns summary A highly vulnerable child was not provided prescribed 2:1 care, their complex package lacked proper review or quality checks, and critical parental concerns were ignored, compounded by inadequate staff training.

Concerns summary The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Concerns summary Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.

Concerns summary Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.

Concerns summary Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack of clarity and potential gaps in ensuring fetal well-being.

Concerns summary The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable crystalline silica, potentially increasing their risk of developing severe diseases.

Concerns summary Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and risking critical issues being missed.

Concerns summary Critical learning issues, including inadequate patient handover procedures for midwives, remained unaddressed a year after the death, with no specific training or effective reflective discussions implemented.

Concerns summary Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.