2022

Concerns summary Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. There was also no documented evidence of information provided to the patient.

Concerns summary The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.

Concerns summary The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious local systemic issue.

Concerns summary A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.

Concerns summary A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of bus and coach driver training.

Concerns summary A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and crucial information not being disclosed.

Concerns summary Inadequate wound care occurred due to reduced clinic attendance without an alternative plan, and the GP prescribed antibiotics without examination. There was no clear process for managing patients declining care or lacking capacity.

Concerns summary The current system illogically allows individuals to purchase and keep a car without possessing a driving license, raising concerns about road safety.

Concerns summary Staff lacked training to immediately call emergency services and were not confident in basic first aid; emergency assistance calls were inefficiently routed, and no advanced first aider was on site.

Concerns summary The council's landlord licensing process lacks prior premises audits and doesn't explicitly address child safety risks like internal blinds. Enforcement for non-compliance is unclear, and tenant certificates are misleading.

Concerns summary Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially impacting care decisions and safety measures.

Concerns summary Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility for safety in this multi-jurisdictional area is poorly defined.

Concerns summary A public bridleway's junction with a main road has severely restricted visibility and lacks measures to slow down cyclists or pedestrians. This design creates a high collision risk, particularly for children.

Concerns summary A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without awareness of the patient's history.

Concerns summary Inadequate signage for a temporary 30 mph speed limit, with higher speed limit signs remaining visible, led to confusion for road users and police. This failure significantly increased the risk of collisions at a known road defect.

Concerns summary A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.

Concerns summary The trust tolerated a blurring of therapeutic escorted leave with unsecure smoking breaks, where one staff member supervised multiple patients in an unsecure car park. This lack of clear boundaries and a safe smoking area allowed patients to abscond with catastrophic consequences.

Concerns summary Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.

Concerns summary There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.

Concerns summary The Trust's serious incident investigation was flawed, hindering learning. Newly appointed obstetric consultants lacked sufficient mentoring and access to senior support for complex emergencies.

Concerns summary Diabetic patients with stable glucose levels lack pre-issued rapid-acting insulin, causing critical delays in treatment when levels rise and risking hyperglycaemic collapse before emergency services attend.

Concerns summary The care home lacked written policies for care planning and review, with falsified records for risk assessments. Families were also denied timely information regarding significant incidents or deprivation of liberty.

Concerns summary A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.

Concerns summary A lack of national guidance on feeding expectations for low-risk, formula-fed babies in their first 72 hours risks premature discharge and insufficient information for families on signs of concern.

Concerns summary The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a serious incident.