2021

Concerns summary Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.

Concerns summary Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of a composite risk assessment and DCMH's primacy in MDT meetings can lead to inadequate risk management.

Concerns summary The "Working with Risk" documentation and care plan for the patient were not completed during the initial nine contacts, which the Trust could not explain, resulting in an unsatisfactory care plan.

Concerns summary Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient to attend in person for benefits.

Concerns summary School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.

Concerns summary Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed to adequately log actions or share critical information with other agencies.

Concerns summary Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or concerns.

Concerns summary Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, posing a risk of misuse.

Concerns summary Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.

Concerns summary Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.

Concerns summary Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration for applying similar approaches to those used for tidal waters.

Concerns summary Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, and insufficient scrutiny of age-inappropriate online content in schools.

Concerns summary Observation charts were potentially pre-populated or manually overwritten without clear indication, leading to inaccurate records. Unregistered staff documenting observations lacked professional regulatory oversight.

Concerns summary Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening for soldiers outside their chain of command were identified.

Concerns summary The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.

Concerns summary There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined responsibilities for guests.

Concerns summary Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.

Concerns summary Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.

Concerns summary Persistent and severe staffing shortages at the rehabilitation hospital compromised patient safety, making it impossible for staff to provide adequate care, particularly for vulnerable patients.

Concerns summary There is an absence of clear local guidance for GPs on safely prescribing multiple high-dose analgesics in the community and when a mandatory referral to a pain specialist is required.

Concerns summary Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and harmful content.

Concerns summary The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.

Concerns summary Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.

Concerns summary Current regulations for Crash Resistant Fuel Systems (CRFS) in rotorcraft are inadequate, failing to mandate retrofits or provide a public register. This leaves a high risk of post-crash fires and prevents informed public decision-making.

Concerns summary Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.