2023

Concerns summary Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.

Concerns summary Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.

Concerns summary The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.

Concerns summary Herefordshire Council's communication failure prevented contact with the deceased, failing to establish his vulnerability for housing support, and highlighted a lack of effective systems for identifying process failures.

Concerns summary The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented communication and depriving patients of crucial collective professional perspectives, risking lives.

Concerns summary The CAA's self-declaration system for older pilots lacks comprehensive medical guidance and a central licence revocation system, allowing revalidation without independent assessment of fitness to fly.

Concerns summary Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting observations, delayed diagnostics, and overall systemic communication and competency breakdowns.

Concerns summary Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was not followed, and staff lacked awareness regarding CT scan requirements.

Concerns summary A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.

Concerns summary Repeat fatal incidents on a specific road bend highlight concerns about inadequate safety measures and a lack of clear timescales for assessing and implementing additional road markings despite discussions between authorities.

Concerns summary A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, creating a serious risk of vulnerable patients absconding.

Concerns summary The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.

Concerns summary The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.

Concerns summary The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and difficulty in accurately auditing prescribing history, posing a risk of medication errors.

Concerns summary Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient leave, has been significantly delayed, raising concerns about ongoing risks.

Concerns summary Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff training, and resource adequacy across council and health services.

Concerns summary Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to prevent future collisions.

Concerns summary There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing immediate inpatient assessment and treatment, which has not improved since 2019.

Concerns summary Police officers failed to document the deceased's recent suicidal ideation on Person Escort Record and Self-Harm warning forms, risking future underestimation or complete disregard of suicide risk for persons in custody.

Concerns summary Widespread, significant ambulance response delays for Category 2 calls, drastically exceeding target times, are caused by multifactorial issues including high demand and prolonged A&E handover times, directly contributing to patient deterioration and death.

Concerns summary Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding GP understanding, CRT prioritization, or triage effectiveness, causing patients to become seriously unwell before assessment.

Concerns summary The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.

Concerns summary The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future reoccurrences.

Concerns summary Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate practitioner-detainee interaction, compromised effective risk management. A manager's review also lacked critical analysis or learning identification.

Concerns summary Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.