2021

Concerns summary Converging surface water on the A390, exacerbated by heavy rainfall, creates a significant aquaplaning risk. Feasible drainage improvements have not yet been implemented despite a previous incident.

Concerns summary Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on prisoners' significant self-harm history.

Concerns summary Unclear scan reporting and inadequate documentation of clinical decisions, including those overriding specialist advice, prevented clinicians from appreciating critical findings and understanding the rationale.

Concerns summary There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.

Concerns summary A lack of shared "high risk" patient definitions and national guidance for shared care plans between trusts led to inconsistent risk assessments. Prolonged mental health bed waits were also exacerbated by fragmented commissioning.

Concerns summary The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.

Concerns summary The Trust's risk assessment policy was not consistently followed by nursing staff. Electronic medical records showed significant validation delays and unapparent post-death amendments, compromising their integrity.

Concerns summary A lack of safety barriers between the highway and a storm drain at a road exit poses a significant risk of cyclists and vehicles falling into it.

Concerns summary Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred policies effectively.

Concerns summary Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed acute conditions.

Concerns summary A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and life-threatening danger.

Concerns summary The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.

Concerns summary A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.

Concerns summary Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs were also not integrated into long-term plans.

Concerns summary An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.

Concerns summary Critical aortic stent leaks were missed on CT scans due to the lack of 3D reconstruction. An external reporting service, Medica, has not committed to implementing this essential practice, leaving patients at risk.

Concerns summary Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk of materials falling from vehicles.

Concerns summary A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent treatment, highlighting a systemic risk of serious harm and death to vulnerable individuals.

Concerns summary A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.

Concerns summary Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate advice and highlighting a lack of clear standards for inter-hospital information exchange.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate during an emergency.

Concerns summary Critical medical device information was missing from patient records, consent forms, and anaesthetic checklists, alongside generally poor documentation quality and specialist nurses failing to act on patient concerns.