2015

Concerns summary (AI summary) A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.

Concerns summary (AI summary) Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.

Concerns summary (AI summary) Critical recommendations for support and care coordination were not actioned, and communication breakdowns meant team members were unaware of appointments. The patient was discharged despite difficulties in engagement and unmet practical needs.

Concerns summary (AI summary) Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.

Concerns summary (AI summary) A lack of signage warning motorists about a concealed entrance posed a significant safety risk, especially for traffic approaching from a particular direction.

Concerns summary (AI summary) Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file retrieval for treatment.