Worcestershire

Concerns summary A critical lack of formal policies and guidance between CCTV operators and police led to confusion over responsibility for calling emergency services, resulting in dangerous delays.

Concerns summary The ACU's generic, pre-populated risk assessment for grass-track events and the lack of a mandatory event-specific safety plan for Club/National events create a significant risk of future deaths.

Concerns summary Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding single anticoagulant use.

Concerns summary Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk assessment and delegation during patient transfers.

Concerns summary Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care for a hard-of-hearing patient.

Concerns summary Hospital clinicians failed to apply critical NICE guidelines for adrenal insufficiency, compounded by overcrowded settings and high staff turnover, which poses a risk to patient safety.

Concerns summary Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.

Concerns summary There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to community care, leading to potential gaps where high-risk patients' needs are not met.

Concerns summary A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of patient needs and critical equipment concerns.

Concerns summary Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies being sold to the public.

Concerns summary Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, risking future underestimation or complete disregard of suicide risk for persons in custody.

Concerns summary A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an intended urgent mental health assessment. This misunderstanding of urgent referral protocols poses a risk of future deaths.

Concerns summary Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a patient with Addison's disease after trauma. Trust guidelines and documentation lacked crucial prompts for adrenal insufficiency.

Concerns summary The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior clinician unilaterally overrode a Multi-Disciplinary Team decision, highlighting a lack of robust procedural oversight.

Concerns summary Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of increased risk and implementation of critical mitigation measures.

Concerns summary HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison staff. The Duty Governor also failed to make sufficient enquiries regarding health screens.

Concerns summary Prison healthcare failed to follow up on significant discrepancies between a prisoner's self-reported mental health and his GP records, particularly concerning past suicide attempts, leaving him vulnerable in early custody.

Concerns summary A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient knowledge, indicating severe systemic failures.

Concerns summary Staff failed to adequately assess a patient's capacity to refuse medication, misapplying the Mental Capacity Act 2005. This led to a delay in administering necessary treatment for extreme anxiety.

Concerns summary A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.

Concerns summary There is insufficient emphasis on maternal wishes and informed consent regarding mode of delivery. Additionally, there's a lack of specific guidance for managing infection risks associated with a retained deceased foetus following feticide.

Concerns summary Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.

Concerns summary HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.

Concerns summary A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, highlighting a gap in following emergency protocols.

Concerns summary The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.