2023

Concerns summary Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check compliance, not correctness, failing to identify errors or training gaps.

Concerns summary There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding discharge risks and Body Dysmorphic Disorder (BDD) treatment. Training on BDD and its associated risks, including aesthetic dermatology, is insufficient, compounded by a lack of national BDD resources.

Concerns summary Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.

Concerns summary Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A comprehensive review of pedestrian crossing provision is needed to prevent future deaths.

Concerns summary Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the property. The source of the carbon monoxide toxicity remains unascertained.

Concerns summary A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation techniques for individuals experiencing psychotic episodes. The officer's training was described as a "patchwork" over many years.

Concerns summary Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety modifications are not universally applied. There is an urgent need to disseminate safety learning and modification awareness throughout the industry.

Concerns summary Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous downhill overtaking section lacks funding for implementation.

Concerns summary Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future deaths. Current actions to address these long delays have been demonstrably ineffective.

Concerns summary The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or IV infusions, in relation to falls risk.

Concerns summary Midwives attending home births had limited experience, highlighting a lack of specific regulatory requirements for training or ongoing exposure to home birth practice. This raises concerns about maintaining competency in all areas of midwifery practice.

Concerns summary Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a lack of training on UVC/IO access and blood transfusions for neonatal resuscitation.

Concerns summary A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.

Concerns summary Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.

Concerns summary A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.

Concerns summary Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.

Concerns summary The falls risk assessment was completed inaccurately and not reassessed despite family warnings about compromised mobility. Furthermore, the Trust's internal investigation failed to identify these critical failures.

Concerns summary Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.

Concerns summary Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.

Concerns summary Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus stenting and associated perforation risks.

Concerns summary Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent approaches and failure to recognize fatal risks.

Concerns summary GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information sharing. The effectiveness of new training and tools remains unconfirmed.

Concerns summary The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.

Concerns summary Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about wider patient safety.

Concerns summary Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of patient allocation because the patient remained in A&E, delaying critical review.