2021

Concerns summary DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors or flexible appointment management.

Concerns summary The Major Trauma Centre lacks a major trauma lead consultant and trauma co-ordinator, which is contrary to NICE guidelines and has been an unresolved issue since at least 2018.

Concerns summary Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.

Concerns summary The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.

Concerns summary Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.

Concerns summary The care home could not adequately observe falls-risk residents during self-isolation due to staffing and lack of guidance. Vulnerable elderly patients sent to hospital alone faced significant communication barriers, hindering their care.

Concerns summary Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.

Concerns summary HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.

Concerns summary The care home failed to follow falls protocols, including not calling 999 after head injuries, delaying emergency services, and not updating care plans or identifying patterns in the deceased's repeated falls.

Concerns summary Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.

Concerns summary Hospital policy does not reflect practice regarding staff roles and fetal monitoring during epidural procedures, indicating a lack of clarity and potential gaps in ensuring fetal well-being.

Concerns summary Care staff failed to address a heating fault during a heatwave and ensure adequate rehydration, leading to the patient's deterioration being unrecognised.

Concerns summary Oxford University lacks an overarching drug misuse policy, and St John's College's conflicting approach of severe penalties versus support may discourage students with addiction from seeking help.

Concerns summary A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have prolonged life.

Concerns summary The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.

Concerns summary The patient was placed in an unsuitable care home, inappropriately discharged by the hospital despite warnings, and suffered an inpatient fall due to inadequate supervision and care for his confused state.

Concerns summary Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, which led to unaddressed severe injuries and no post-death investigation.

Concerns summary The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable crystalline silica, potentially increasing their risk of developing severe diseases.

Concerns summary National guidelines and the Red Book lack specific directives for Vitamin D supplementation advice for babies by Health Visitors and for at-risk women, particularly those breastfeeding or with increased skin pigmentation.

Concerns summary The landlord rented out a non-compliant cellar flat, raising concerns about similar hazards, including inadequate smoke detection and escape routes, in other properties. There is no ongoing duty for landlords to check smoke alarm effectiveness.

Concerns summary Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly identify stationary vehicles, necessitating better driver awareness and a wider public inquiry beyond inquest limitations.

Concerns summary Shooting range staff lack consistent national training in identifying abnormal behaviour or conducting emergency response exercises, which could significantly improve safety protocols for participants.

Concerns summary Oxygen cylinder regulators present an ignition risk, possibly due to incorrect valve operation by paramedics lacking knowledge of safety protocols, with multiple reported incidents despite no identified device defects.

Concerns summary Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he could contact someone for assistance, a script deficiency later partially addressed.

Concerns summary Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending a deceased person's address.