2019

Concerns summary Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.

Concerns summary A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, causing distress and inadequate support prior to discharge.

Concerns summary A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at severe risk.

Concerns summary Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.

Concerns summary The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would be followed to prevent future deaths.

Concerns summary A crisis line call taker failed to directly ask about suicidal ideation, despite knowing the patient's recent discharge from the emergency department for intending to jump, missing a critical intervention opportunity.

Concerns summary The report provided no specific details regarding the matters of concern, indicating a placeholder or incomplete entry.

Concerns summary The report provided no specific details regarding the matters of concern, indicating a boilerplate introduction without further content.

Concerns summary Failures in conducting formal carer's assessments and irregular contact by the case coordinator led to outdated care plans and risk assessments, a critical oversight not identified by supervisory reviews.

Concerns summary Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented responsibility across multiple agencies with poor communication and separate IT systems.

Concerns summary Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities to diagnose cancer and cancelling vital appointments due to resource shortages across multiple agencies with separate databases.

Concerns summary Inadequate patient counselling and insufficient warnings on medication packaging failed to address the dangers of exceeding doses, self-medicating, and unmeasured consumption.

Concerns summary The ambulance service lacks a protocol to engage other emergency services for assistance or updates during significant delays when there is no direct observation of the scene.

Concerns summary Critical donor CMV status was not communicated to the deceased, preventing informed consent due to failures in the transplant team's information sharing process and documentation transfer.

Concerns summary The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system installation, despite evidence of their life-saving potential.

Concerns summary Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.

Concerns summary A busy junction and pedestrian crossing is dangerously designed, allowing no margin for error for either pedestrians or drivers, and has led to multiple similar deaths.

Concerns summary There's a systemic failure to provide integrated treatment for co-occurring serious mental illness and substance misuse, hampered by poor information sharing and an outdated Mental Health Act.

Concerns summary CQC inspections fail to consistently include external premises areas routinely used by residents, risking overlooked safety issues outside the immediate care environment.

Concerns summary The fact that a member of the public discovered the body on the railway platform raises concerns about monitoring and detection systems.

Concerns summary There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, despite clear guidance for lower limb procedures.

Concerns summary Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause Analysis report.

Concerns summary Inadequate and unchased referrals to the Tissue Viability Nurse, combined with systemic failures in detailed wound record-keeping, led to delayed and insufficient care for severe leg ulcers.

Concerns summary Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked a system for recording such information.

Concerns summary Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded by poor integration between care, mental health, and educational support services.