2015

Concerns summary Critical lack of communication between offender managers and hospital clinicians before recall, alongside widespread confusion among probation staff about the recall process, created systemic failures.

Concerns summary Crucial information about clinic attendance and referrals was not communicated or documented. Junior doctors handled specialist consultations, and a urologist failed to review a patient with suspected malignancy and significant symptoms.

Concerns summary Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised that diverting this byway could merely shift the problem elsewhere.

Concerns summary Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.

Concerns summary Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.

Concerns summary Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.

Concerns summary Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.

Concerns summary A product containing isopropyl nitrite, misused by inhalation, has inadequate labelling that fails to comply with current safety regulations (CLP) regarding hazards and warnings.

Concerns summary Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.

Concerns summary Critical failures included a lack of blood pressure monitoring and aneurysm screening after prison transfer, alongside ambulance call delays due to the absence of an emergency protocol.

Concerns summary Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an unsafe mirror.

Concerns summary A serious design flaw on the Kingsway/Metro system has led to over 100 road traffic incidents, including injuries and two fatalities, involving pedestrians and coaches.

Concerns summary The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.

Concerns summary The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect with independent research on consumer safety.

Concerns summary Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.

Concerns summary Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct contact to assess their capacity or needs.

Concerns summary Delays in calling ambulances following emergency medical codes and inconsistent adherence to prison protocols for medical emergencies represent a recurring and dangerous systemic failure.

Concerns summary Ambiguous national instrumental delivery guidance and misaligned trust protocols, particularly concerning procedure abandonment criteria and traction terminology, created risks during childbirth.

Concerns summary Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.

Concerns summary Failure to timely liaise with a tertiary care center regarding a patient's complex medical history and specific requests delayed critical investigations, missing opportunities to prevent deterioration.

Concerns summary Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.

Concerns summary Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.

Concerns summary The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of future deaths.

Concerns summary Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked training to access historical imaging.

Concerns summary There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.