2022

Concerns summary Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.

Concerns summary A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to undertake dangerous grass strimming, hindering life-saving operations.

Concerns summary Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.

Concerns summary Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.

Concerns summary Recurring serious issues include unclear sedation doses, poor documentation, delayed recognition of patient deterioration, inadequate medical involvement, and delays in emergency access, indicating unaddressed systemic failures.

Concerns summary Outdated IV fluid guidelines for children in shock posed a risk of fluid overload, and there was no clear guidance on balancing antibiotic use for sepsis against the risk of HUS in bacterial gastroenteritis.

Concerns summary The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to others or multi-agency information sharing for risk management.

Concerns summary Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This service gap may exist nationally.

Concerns summary A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.

Concerns summary Paramedics lacked training in administering buccal midazolam and failed to effectively oxygenate or suction a fitting child, despite clear recommendations from a serious incident report.

Concerns summary A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses and treatment delays.

Concerns summary The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.

Concerns summary There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures at diving centres.