2019

Concerns summary Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.

Concerns summary The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.

Concerns summary Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.

Concerns summary A dark section of the A693, serving as an unofficial pedestrian crossing point with a 60mph speed limit and no street lighting, creates a critical hazard where vehicle stopping distances exceed driver visibility.

Concerns summary An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, thus frustrating necessary assessments and interventions.

Concerns summary Systemic failures in child safeguarding include unclear referral pathways, delayed responses to urgent concerns, insufficient multi-agency understanding of complex family dynamics, and inadequate information sharing regarding children's welfare in private law proceedings.

Concerns summary Poor record-keeping, including incorrect care plan entries and lack of documentation for referrals, indicates inadequate staff training and poses risks to patient care and safety.

Concerns summary A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or users, about this safety hazard.

Concerns summary Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.

Concerns summary A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to significant mortality and morbidity risks.

Concerns summary Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.

Concerns summary Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.

Concerns summary Delays in emergency calls due to lack of cordless phones, combined with triage systems requiring real-time patient information that callers remote from the patient cannot provide, risk inadequate and delayed emergency response.

Concerns summary The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical transition period.

Concerns summary A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.

Concerns summary Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.

Concerns summary Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.

Concerns summary Safety on a road known for speeding and overtaking would be improved by extending double white lines to restrict dangerous overtaking maneuvers.

Concerns summary There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient creams, which impregnate clothing and accelerate burns.

Concerns summary Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged debris.

Concerns summary Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex cases.

Concerns summary There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with staff lacking understanding of police protocols and information requirements, leading to delayed high-risk classification.

Concerns summary The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear welfare check protocols for security staff, and inadequate risk assessment updates, without policy for GP contact.

Concerns summary The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.