2020

Concerns summary The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.

Concerns summary Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.

Concerns summary The nurse in charge lacked training for patient arrest, panicked, left a collapsed patient with an untrained HCA, and performed incorrect resuscitation, demonstrating severe gaps in emergency response.

Concerns summary The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.

Concerns summary Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.

Concerns summary An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons learned or staff training.

Concerns summary There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.

Concerns summary A fatal road collision involving an agricultural vehicle with a protruding boom highlights the need for a review of road layout, signage, and safety improvements at the A5 junction.

Concerns summary The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review medication side-effect monitoring protocols.

Concerns summary Inadequate and poorly located beach signage, insufficient surveillance, and lack of warnings contributed to fatalities, suggesting a need for improved information boards and increased beach patrol presence.

Concerns summary Lack of waterproof fetal heart rate monitoring equipment during birthing pool delivery, coupled with incorrect newborn resuscitation techniques by midwives and infrequent mandatory training, contributed to the death.

Concerns summary Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.

Concerns summary The absence of a pedestrian crossing on the A12 near a fatal collision site, coupled with delays in implementing a traffic management order and building a new crossing, poses ongoing risks.

Concerns summary Repeated pedestrian fatalities at an uncontrolled crossing point, driven by bus stop proximity and inadequate lighting, highlight an urgent need for a new controlled crossing and neglected funding applications.

Concerns summary The Red Book's prominent co-sleeping advice misleadingly omits the critical warning against co-sleeping with premature or low birth weight babies from its quick-reference "Don'ts" section.

Concerns summary Easy public access to a restricted dam, inadequate signage, and exposed live wiring led to an electrocution, with no explanation or report on building regulations enforcement provided.

Concerns summary Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises concerns about adequate care provision.

Concerns summary Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper policy, training, or consistent application.

Concerns summary Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately assess and refer individuals requiring urgent mental health support.

Concerns summary A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.

Concerns summary Inadequate adherence to specialist nutritional guidelines, including providing inappropriate food and failing to escalate concerns, coupled with a lack of thickener for fluids, contributed to patient neglect.

Concerns summary The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.

Concerns summary There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make appropriate specialist referrals for a deteriorating patient.

Concerns summary Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.

Concerns summary Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.