2020

Concerns summary Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.

Concerns summary GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded by deficient CCG guidance on dosage.

Concerns summary A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the same location, necessitating a review of safety restrictions and drainage.

Concerns summary West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.

Concerns summary Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a need for clearer guidance on how such temporary accommodations are classified under the Act.

Concerns summary Guidelines for declaring death on scene (ROLE) need urgent clarification, especially regarding assumptions about imminence or difficulty of extraction. Ambulance crews also lacked awareness of fire service capabilities for vehicle lifting, hindering decision-making.

Concerns summary A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.

Concerns summary Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.

Concerns summary A patient's family was not given clear, specific guidance on the definition of "bite-sized" food according to IDDSI standards for dysphagia, nor tailored advice for their cultural diet and eating practices.

Concerns summary Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.

Concerns summary Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, at a mental health facility.

Concerns summary There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments are inadequate for both pedestrians and staff on the track.

Concerns summary The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a safety flaw.

Concerns summary Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.

Concerns summary There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally required annual Care Act reviews due to resource constraints.