2021

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 A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.

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 Admitting unsupervised 16-17 year olds to festivals where illicit drugs and alcohol are prevalent exposes vulnerable teenagers to significant harm, raising concerns about licensing bodies' responsibility.

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 The care home failed to update skin and mobility care plans, ensure regular repositioning, or recognise a deteriorating medical condition (cellulitis), leading to delayed medical assistance and an inadequate post-death review.

Concerns summary National training for prison staff lacks clear guidance on the safe use of force when prisoners have items in their mouths, posing a risk to breathing.

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.

Concerns summary Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.

Concerns summary A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for hours after a fall.

Concerns summary An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.

Concerns summary Systemic failures included misinterpretation of CT scans, staff unawareness of patient spinal conditions and equipment features, incomplete fall assessments, and unrecorded adverse reactions to procedures.

Concerns summary Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.

Concerns summary Unrestricted online access to detailed suicide instructions and the ability to purchase lethal quantities of substances without safeguards pose significant risks to vulnerable individuals.

Concerns summary A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a risk of further missed appointments.