2020

Concerns summary Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.

Concerns summary The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.

Concerns summary Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.

Concerns summary Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, or temporary speed limits, creates a high-risk environment for students.

Concerns summary Concerns exist regarding whether an appropriate operating or instruction manual was obtained for the inflatable trampoline, which exploded and caused a fatality.

Concerns summary Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require a named local consultant and consultation with the overseeing hospital's specialist department upon admission.

Concerns summary Lack of clear guidance on paraglider speed bar specifications, absence of speed bar inspection in pre-flight checks, and insufficient consideration for pilot size/weight in system configuration pose safety risks.

Concerns summary Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.

Concerns summary HGV training lacks mandatory instruction on Class VI mirror use, which covers blind spots, and not all drivers are required to undertake vulnerable road user awareness courses, increasing collision risks.

Concerns summary There is no speed limit on the road adjacent to the school, failing to slow traffic during critical times when children are arriving and leaving the school.

Concerns summary Valuable non-crime domestic abuse information is fragmented and not available as a national police resource, hindering effective safeguarding of potential victims.

Concerns summary The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates risks of misuse or environmental harm.

Concerns summary A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.

Concerns summary Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red flag" warning system for suicide risk.

Concerns summary A significant delay in defibrillation occurred because the paramedic was distracted and the device defaulted to manual mode; this is a recurring issue, reducing survival prospects.

Concerns summary Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly led to inadequate risk assessments and missed opportunities for mental health intervention.

Concerns summary Insufficient communication of blind cord dangers to new parents, absence of a national safety leaflet, and missed opportunities for healthcare professionals to provide warnings contributed to the risk.

Concerns summary An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in community patients posed significant risks.

Concerns summary A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.

Concerns summary Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.

Concerns summary Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.

Concerns summary Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting a systemic failure in information sharing.

Concerns summary Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.

Concerns summary There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.

Concerns summary Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.