Worcestershire

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 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 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 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 Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.

Concerns summary West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.

Concerns summary A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental state and specific concerns not being recorded.

Concerns summary The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.

Concerns summary The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its possession or supply illegal.

Concerns summary The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with the care team.

Concerns summary Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.

Concerns summary Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.

Concerns summary A critical policy for tracking patients discharged between services has not been implemented since 2015, despite being identified as necessary by a Root Cause Analysis, indicating a failure in governance.

Concerns summary Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.

Concerns summary There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.