2022

Concerns summary Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's hydration policy, leading to patient dehydration without clear accountability.

Concerns summary A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about the adequacy of current regulations and strength assessments for harness fitting points in cars.

Concerns summary Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. There is also a critical shortage of consultant midwives providing obstetric support across ambulance services.

Concerns summary A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting MAPPA professionals, posing a risk of future deaths.

Concerns summary The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns about inadequate pre-treatment assessment and the need for mandatory First Aid training for chiropractors.

Concerns summary Malnutrition screening training is insufficiently completed and not mandatory for all relevant staff, while the critical Nutrition and Hydration Committee suffers from inconsistent support and attendance.

Concerns summary Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of their suitability to possess weapons when facing prosecution.

Concerns summary External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading to potential delivery of conflicting care and an unsafe environment.

Concerns summary The decision not to commence CPR was contrary to both Trust and National Policy, potentially impacting patient outcomes.

Concerns summary The emergency dispatch algorithm fails to account for anticoagulant medication in head injury cases, risking delayed appropriate responses and future deaths.

Concerns summary Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a review of literature and adverse event reporting.

Concerns summary The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high demand on EDs, fueled by broader health and social care failures.

Concerns summary The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.

Concerns summary A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged waiting times (up to 63 weeks) for treatment. Current services and resources are insufficient to meet this drastically increased demand.

Concerns summary Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware of actions to mitigate thromboembolic risks.

Concerns summary Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health decline, hindering timely and private support.

Concerns summary A known risk of the deceased taking a spouse's medication was not documented, assessed, or managed by the Trust, and this critical systemic failure was overlooked in their internal investigation.

Concerns summary “Carer breakdown” was inadequately defined and not addressed during hospital admission or discharge. Without a clear process to involve carers, patients could be discharged without essential support.

Concerns summary Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical intervention, creating significant safety gaps.

Concerns summary The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical input and limited learning from a serious event. Trust-wide policy review and comprehensive retraining are urgently required.

Concerns summary A care home failed to promptly call an ambulance for a critically ill patient, maintained incomplete nursing and medication records, and staff lacked sufficient patient knowledge, indicating severe systemic failures.

Concerns summary The coroner questioned why charges under the Children and Young Persons Act were not brought against the parents, given the evidence presented.

Concerns summary Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.

Concerns summary Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.

Concerns summary There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.