2019

Concerns summary A critical 6-month delay in reporting prevented a curable treatment option, likely altering the outcome, and there was a lack of leading physician sign-off on reports.

Concerns summary Failure to conduct a crucial blood test, as per national guidelines, masked Endocarditis, leading to a missed diagnosis and delayed treatment that would likely have resulted in a different outcome.

Concerns summary Confusion among staff regarding voluntary patients' leave status highlighted the absence of a specific leave policy for voluntary patients, unlike those sectioned under the Mental Health Act.

Concerns summary Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative antiemetics.

Concerns summary The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures for upright embedment are subjective and inadequate to ensure structural integrity.

Concerns summary A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout and lack of traffic calming measures.

Concerns summary The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency response where police powers are limited despite their primary responsibility.

Concerns summary A road with unusual features, despite appropriate signage, facilitates excessive speeding and has a history of multiple fatal collisions. Traffic calming measures are needed to reduce future risks.

Concerns summary Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.

Concerns summary Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively impacted patient care. A carer's assessment was also not offered.

Concerns summary The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications being continued and a lack of proper rationale for prescribing.

Concerns summary The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.

Concerns summary Inadequate, text-only signage and a lack of physical barriers create a significant drowning risk in an area of the lake frequented by families. Contractors were also not sufficiently informed of the rules.

Concerns summary The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a significant hazard for pedestrians.

Concerns summary There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.

Concerns summary Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.

Concerns summary Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.

Concerns summary The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.

Concerns summary The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.

Concerns summary Inadequate assessment and treatment of a vulnerable patient before discharge, unclear clinician responsibility, poor communication, insufficient discharge summaries, and medication errors highlighted a concerning culture of acceptance.

Concerns summary Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, impacting the deceased's treatment.

Concerns summary A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's a risk of similar incidents occurring again.

Concerns summary The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to significant delays in hospital admission.