2019

Concerns summary Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.

Concerns summary Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's continued operation with inadequate care and record-keeping poses a significant risk of future deaths.

Concerns summary The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.

Concerns summary A significant gap in mandatory basic life support training for prison officers employed during a specific period leads to delayed CPR, with no retrospective training efforts to rectify this.

Concerns summary Care home staff lacked regular refresher training on policies and procedures. Inconsistent policies regarding medication refusal across different homes created confusion and potential risks.

Concerns summary Emergency control room operators failed to prompt callers to request appropriate water rescue services or use specific location signage for a person in the river, causing significant delays in emergency response.

Concerns summary Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original prescribers regarding suspended medications.

Concerns summary The station lacked a clear flow chart or plan to guide staff on appropriate steps to take when a person falls ill, risking further injury.

Concerns summary HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.

Concerns summary The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.

Concerns summary The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.

Concerns summary There is a lack of specific guidance for post-mortem examinations in firearms deaths, especially for children. Assumptions of suicide risk cursory investigations, potentially leading to undetected homicides.

Concerns summary There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.

Concerns summary Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.

Concerns summary Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. Its hyperinfection syndrome presents with non-specific symptoms, risking severe progression.

Concerns summary A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a child with complex needs. Inconsistent understanding of protocols and the "red book" exacerbated these issues.

Concerns summary Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts and a lack of a region-wide approach mean the problem is merely displaced rather than resolved.

Concerns summary Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. Furthermore, safeguarding matters were not logged when individuals were subject to deportation.

Concerns summary Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a less safe system.

Concerns summary The report identified unspecified matters of concern indicating a risk of future deaths.

Concerns summary A mental health trust failed to follow up and share information with the Probation Service regarding a patient associating with a high-risk individual. This breakdown in inter-agency communication prevented consideration of further safeguards.

Concerns summary Critical information about septicaemia risk from NHS 111 was not transferred to ambulance crews and GPs, hindering clinical decision-making. Additionally, ambulance delay notifications for urgent cases are inadequate, risking rapid patient deterioration.

Concerns summary The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.

Concerns summary A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with inadequate monitoring and challenges to deceit.

Concerns summary Employees are repeatedly exposed to polycyclic aromatic hydrocarbons without protective equipment, despite a clear link to cancer, posing a significant ongoing health risk.