2020

Concerns summary There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.

Concerns summary Multiple qualified staff failed to identify fractures on CT scans and X-rays, possibly due to a shortage of radiologists and inadequate review processes, raising concerns.

Concerns summary Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.

Concerns summary Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.

Concerns summary The incident resulted from a lack of safe loading and lifting plans, absence of a banksman, inadequate designated safe zones for drivers, and insufficient equipment for handling large products.

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 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 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.

Concerns summary Group B Strep infection risks were not discussed during pregnancy, screening was not offered, and antibiotics were not administered, potentially contributing to the baby's death.

Concerns summary The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health conditions.

Concerns summary A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.

Concerns summary Inadequate staffing led to staff not listening to family, poor cleanliness, delayed antibiotics, and multiple failures in administering time-critical Parkinson's medication.

Concerns summary The absence of safety signage on a public footpath near a severe drop at a reasonably frequented viewing spot poses an avoidable risk of fatal falls.

Concerns summary Inadequate legislation and a lack of internet sales prohibitions allow dangerous DNP 'diet pills' to remain readily available online, leading to numerous deaths among vulnerable people.

Concerns summary Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.

Concerns summary Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and posing a foreseeable risk of drawing individuals into self-harm.

Concerns summary A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between local authorities.

Concerns summary Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.

Concerns summary Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.

Concerns summary The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.

Concerns summary A paramedic failed to follow recognized protocols, not transferring a seriously ill patient to hospital for a full assessment, indicating a need for procedure review and revision.

Concerns summary The deceased accessed Dinitrophenol (DNP), a drug banned in the UK since 1938 due to its harmful effects, via the internet, likely influenced by social media, leading to his overdose.

Concerns summary The deceased, with dementia, continued driving despite medical advice, highlighting a systemic risk where current legislation places primary responsibility on the driver to inform the DVLA rather than mandating direct clinical referral.

Concerns summary The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.

Concerns summary Inadequately lit, carpeted steps at the venue were difficult to recognise, posing a fall hazard, particularly for those with poor eyesight, with no evidence of post-accident safety examination.