2018

Concerns summary Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.

Concerns summary Systemic failures included ward staff difficulties escalating welfare concerns and making 111 calls, inadequate NWAS investigation and triage by untrained staff, and police confusion over Section 136 powers at private homes.

Concerns summary Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.

Concerns summary Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in medical intervention.

Concerns summary Impeded exit routes and obstructed handrails due to steward placement, coupled with non-compliance with steward codes and lack of audits, compromised public safety at the football ground.

Concerns summary Obscured street lighting, faded road markings, and an ineffective speed cushion created hazardous road conditions, compromising pedestrian and motorist safety.

Concerns summary Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols raised concerns for patient safety.

Concerns summary Lack of assessment for PEG feeding suitability/volume for an end-of-life patient, unaddressed family concerns, and poor understanding between healthcare teams regarding decision-making, created unsafe care practices.

Concerns summary A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.

Concerns summary A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.

Concerns summary Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.

Concerns summary Care home staff dishonesty regarding patient observations and GP calls, coupled with inaccurate records, indicated serious failures. Management surprisingly deemed the care reasonable despite these issues.

Concerns summary A busy A3054 lacks safe pedestrian crossing points, especially for elderly individuals with mobility issues, forcing them to cross dangerously. This hazardous situation has resulted in multiple accidents and near-misses.

Concerns summary The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.

Concerns summary Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.

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

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 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.