2020

Concerns summary Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.

Concerns summary Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, which lack interoperability and require manual input.

Concerns summary Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.

Concerns summary There is widespread illegal dealing of prescription drugs to vulnerable individuals, indicating a critical failure in stemming the leakage of medication from lawful dispensing into criminal hands.

Concerns summary A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under a misleading description, posing significant public safety risks.

Concerns summary National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement for NHS Trusts to ensure clinician familiarity or policy compliance with existing guidelines.

Concerns summary Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor documentation of suicidal disclosures.

Concerns summary There are concerns about the inadequate nature and extent of basic life support and first aid training provided to Gwent police staff, despite their regular contact with unwell or injured individuals.

Concerns summary Critical funding for peer support workers, who offer invaluable 'lived experience' and essential support for mental health and substance misuse, may be lost, jeopardizing vital services.

Concerns summary Systemic failures in domestic abuse management included inadequate police training on risk assessment and coercive control, poor information sharing with CPS, and insufficient use of protective measures like bail and DVPNs.

Concerns summary Persistent staff shortages led to patients being kept overnight in unsuitable clinical areas, with the Trust failing to address reported staffing issues or implement requested increases.

Concerns summary Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.

Concerns summary Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.

Concerns summary Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.

Concerns summary Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.

Concerns summary The A20 Ashford Road lacks parking restrictions and requirements for warning signage, allowing large vehicles to park unsafely and posing a significant risk to other road users.

Concerns summary Dangerous road conditions on the A66 include a lack of pedestrian warnings, rapid acceleration onto an unlit section, poor lighting, and national speed limit signs placed too close to a roundabout.

Concerns summary Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a failure to properly escalate concerns about its function were identified.

Concerns summary Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.

Concerns summary The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.

Concerns summary Hospital staff lacked sufficient specialist mental health advice to properly assess and mitigate falls risks for patients with mental health needs, leading to inadequate care plans.

Concerns summary Incomplete patient records, difficulty contacting on-call medical staff, and a critical failure to refer the patient for post-discharge monitoring created significant care gaps.

Concerns summary The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.

Concerns summary Inadequate record-keeping of care provided and medication dosage made it impossible to corroborate staff actions and risked erroneous or duplicated patient care.

Concerns summary A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.