2023

Concerns summary The care home demonstrated inadequate resident monitoring and failed to promptly review new residents' care plans. There was no clear policy or training for staff to address residents with unusual presentations.

Concerns summary The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at increased self-harm risk, and did not ensure required weekly reviews.

Concerns summary The hospital failed to contact the patient's emergency contacts upon discharge, leaving her unsupported. No follow-up appointment was made, and attempts to contact her post-discharge were significantly delayed.

Concerns summary The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly given the potential for recipients to have mental health issues from combat service.

Concerns summary Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.

Concerns summary The Trust's emergency response was critically flawed, with delays and poor communication during an emergency. Known safety risks, including non-closing doors to high-risk areas, were inadequately mitigated, and the internal investigation was unreliable.

Concerns summary Informal staff arrangements and insufficient staffing levels led to inadequate supervision of residents. There was also a lack of post-incident review and management oversight.

Concerns summary The Trust failed to address known drowning risks at a lake, with inadequate supervision, missing water depth warnings, and inaccessible life-saving equipment.

Concerns summary Systemic failures in care for trans persons on a Personality Disorder Pathway included a lack of dedicated contact, inadequate staff training, poor assessment protocols, and insufficient mental health support.

Concerns summary Oncology consultants inappropriately lead care for APML patients, where significant bleeding risks require haematologist expertise, exacerbated by a national shortage of specialists.

Concerns summary Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police forces due to a lack of standardized cross-border protocols.

Concerns summary Porthleven Harbour and its pier presented significant safety risks due to sheer drops, absent railings, poor lighting, trip hazards, and a lack of escape provisions for anyone falling into the water.

Concerns summary Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was taken despite police notification of the problem.

Concerns summary Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, with current improvements proving extremely limited.

Concerns summary Deficient discharge planning for a child with delayed autism diagnosis and high suicide risk stemmed from insufficient assessment, poor council response to referrals, and a lack of understanding of Mental Health Act rights.

Concerns summary Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a widespread lack of understanding of safe fixing practices among farmers and inspectors.

Concerns summary Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks proactive monitoring.

Concerns summary GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.

Concerns summary The hospital failed to implement critical safety undertakings related to placenta retention and staff training, despite previous commitments, raising serious concerns about continued risks.

Concerns summary The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially to vulnerable pedestrians.

Concerns summary Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including attempted suicide.

Concerns summary There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.

Concerns summary Individuals are being released from police custody far from home without adequate means for transport or communication, risking their safe return and welfare.

Concerns summary Inadequate traffic management measures around the school pose an ongoing risk of future deaths, necessitating immediate investigation and improvement.

Concerns summary Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.