2021

Concerns summary Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.

Concerns summary GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for vulnerable patients.

Concerns summary Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.

Concerns summary Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.

Concerns summary A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment method was insecure, posing risks for similar helmet-mounted accessories.

Concerns summary Hospital failed to assess or treat a patient with psychiatric issues, did not follow discharge protocols for self-discharge, and neglected to inform external mental health teams, leading to a dangerous gap in care.

Concerns summary There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.

Concerns summary Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.

Concerns summary There was a lack of timely and effective handover between surgical specialties, compounded by an absence of formal protocols and a lack of engagement from plastic surgeons during and after an incident.

Concerns summary HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.

Concerns summary Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.

Concerns summary A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, and suffering from poor sight lines.

Concerns summary A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.

Concerns summary A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an inadequate auditing process.

Concerns summary A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, leading to unnecessary imprisonment, particularly over bank holidays.

Concerns summary Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.

Concerns summary An elderly, confused patient in A&E spent over 7 hours without a falls risk assessment or trolley rail assessment, highlighting a lack of national guidelines for falls prevention in emergency departments.

Concerns summary Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.

Concerns summary There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.

Concerns summary Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff member was CPR trained, violating policy.

Concerns summary The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care and risk planning.

Concerns summary Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than keeping an open mind about alternative routes.

Concerns summary There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.

Concerns summary GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.

Concerns summary An improperly placed, non-functional flat screen monitor in a crop sprayer cab created a dangerous blind spot, obstructing the driver's view of a cyclist.