2022

Concerns summary A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system places an onerous burden on drivers and limits pursuit managers' real-time oversight.

Concerns summary Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.

Concerns summary Ferritin levels were not routinely measured in patients receiving frequent platelet transfusions, risking undetected iron overload, largely due to a lack of funding for chelation therapy.

Concerns summary National safeguarding guidance for children omits "obesity" as a sign of neglect, contrasting with malnourishment, which risks failing to identify and protect obese children at risk.

Concerns summary The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring for vulnerable residents with complex mental health and substance misuse needs.

Concerns summary A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.

Concerns summary Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.

Concerns summary Critical failures in patient monitoring equipment management included staff unawareness of alarm settings, undocumented changes, ignored "OFF COMS" alerts, and unclear protocols for disconnections.

Concerns summary Inadequate fire risk assessments and an unregulated telecare sector fail to ensure vulnerable residents receive essential safety provisions and monitoring, exacerbated by a lack of person-centred risk assessments and accreditation.

Concerns summary A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are "inevitable," compounded by unchecked patient discharge decisions.

Concerns summary An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.

Concerns summary Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.

Concerns summary Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.

Concerns summary Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.

Concerns summary A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and a lack of effective signage or road design to mitigate risks.

Concerns summary Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.

Concerns summary A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.

Concerns summary Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.

Concerns summary Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.

Concerns summary A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to their well-being.

Concerns summary The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.

Concerns summary A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.

Concerns summary Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.

Concerns summary Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.

Concerns summary Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent medical care.