2021

Concerns summary A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding of the inherent risks.

Concerns summary A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.

Concerns summary The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.

Concerns summary Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.

Concerns summary The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management protocols.

Concerns summary The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.

Concerns summary There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.

Concerns summary Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.

Concerns summary The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.

Concerns summary The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.

Concerns summary A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.

Concerns summary Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.

Concerns summary The healthcare system lacks sufficient provision for sustained supported eating for anorexia nervosa patients, leading to ineffective hospital admissions and hindering patient improvement despite clinical recommendations.

Concerns summary An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.

Concerns summary The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.

Concerns summary Insufficient and unreliable IT facilities hinder timely electronic record-keeping, forcing staff to rely on memory or paper notes, which results in unrecorded or omitted crucial clinical information.

Concerns summary Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.

Concerns summary Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.

Concerns summary Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use of the mobility aid.

Concerns summary Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.

Concerns summary A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.

Concerns summary Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific training in identifying such bleeding.

Concerns summary The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to discern turning intentions.

Concerns summary The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.

Concerns summary Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.