2023

Concerns summary Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in patient discussion and transfer.

Concerns summary Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.

Concerns summary Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.

Concerns summary An online book providing explicit, step-by-step suicide instructions, including methods to avoid detection, is readily accessible with inadequate age verification, posing a significant risk to vulnerable individuals.

Concerns summary Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.

Concerns summary Systemic failures include a lack of demonstrated cultural change in patient care, inadequate risk assessment and management, poor information sharing, and insufficient management of intermittent observations.

Concerns summary Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.

Concerns summary Independent mental health assessors lack mandated access to full patient records, while staff misunderstand voluntary admission and the "least restrictive option," potentially hindering appropriate care.

Concerns summary The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.

Concerns summary Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to include all staff in notifications for highly transmissible cases.

Concerns summary The local authority lacks systems to record, track, and confirm action on highway complaints and defects, meaning reported hazards may not be remedied and posing a clear risk of future fatal road incidents.

Concerns summary A cost barrier in private healthcare discourages patients from crucial histological analysis of lesions, unlike NHS treatment where it's included, risking delayed cancer detection for those not meeting NHS referral criteria.

Concerns summary Hospital staff failed to conduct a mental health assessment for a patient with obvious self-harm and suicidal ideation, contradicting NICE guidelines. Critical suicidal ideation was also not adequately recorded.

Concerns summary Dangerous junior orthopaedic staffing and inaccessible NEWS charts during ward rounds meant consultants were unaware of deteriorating patient conditions. There was also confusion among doctors regarding patient responsibility.

Concerns summary Identified systemic failures in mental health services were not effectively addressed. Significant delays in Serious Incident Investigations (9 months) compromise evidence quality, hindering prompt learning and improvement in patient safety.

Concerns summary The Trust's investigation was incomplete and delayed, failing to address critical issues like inadequate staff observations and security breaches on a locked mental health ward. A dispute over permitted items and failure to escalate risk were also concerns.

Concerns summary An external concrete staircase presented worn, un-highlighted steps lacking non-slip surfaces, an inadequately short handrail, and poor lighting, increasing the risk of falls.

Concerns summary The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.

Concerns summary A lack of clear guidance for prescribing intravenous Acyclovir, instead of ineffective oral medication, potentially led to incorrect treatment and preventable death for the patient.

Concerns summary A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.

Concerns summary A nationwide shortage of care providers and carers prevents commissioned care packages from being fulfilled, risking individuals not receiving necessary care with potentially fatal results.

Concerns summary Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.

Concerns summary Known highway defects, including surface water and flooding, were not remedied by the local authority, posing a clear risk of future fatal road incidents.

Concerns summary Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.

Concerns summary Custody sergeants lacked understanding of Liaison and Diversion team processes, available information, and how to complete pre-release risk assessments. This indicates a training need for recognizing vulnerability at discharge.