2018

Concerns summary Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.

Concerns summary A dangerous cluster of student deaths from the bridge, including three this year and four in two years, raises serious concerns about safety at this historical site.

Concerns summary Systemic failure in multi-agency review and responsibility for known home safety risks linked to mental illness was compounded by poor communication and inadequate mental health documentation. Family support was also insufficient.

Concerns summary The withdrawal of funding for MIND's counselling services by the Council and CCG risks future deaths from self-harm and suicide among vulnerable individuals.

Concerns summary The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or address consent for information sharing, creating a significant care gap.

Concerns summary A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals and the importance of timely medical intervention.

Concerns summary The hospital lacks arrangements for obtaining out-of-hours radiology reports for X-rays, unlike its provision for CT and MRI scans.

Concerns summary A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading to obscured views and high risk for pedestrians and cyclists.

Concerns summary Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.

Concerns summary Railway stations lack immediate and effective alert systems for detecting and reporting persons on the line.

Concerns summary Private hospitals' NEWS escalation policies need reviewing due to limited critical care capacity. Post-operative care for complex procedures is concerning as general ward staff may lack specific training for rare complications.

Concerns summary Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.

Concerns summary Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.

Concerns summary Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.

Concerns summary Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.

Concerns summary Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.

Concerns summary The absence of street lighting in a dark area with bus stops near a popular venue creates a significant road safety risk for pedestrians.

Concerns summary GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.

Concerns summary Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.

Concerns summary There were significant delays in defibrillator deployment and ambulance access due to equipment placement, lack of staff direction, and insufficient emergency training, coupled with inadequate medical emergency risk assessments.

Concerns summary Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.

Concerns summary A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.

Concerns summary The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.

Concerns summary The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted in a lack of documented doctor input.