2023

Concerns summary Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.

Concerns summary Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating policy. Premature discharge from community treatment lacked engagement and proper care coordination.

Concerns summary There is a lack of specialist staff training in moving and handling individuals, especially regarding safe procedures after a fall.

Concerns summary High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of work.

Concerns summary An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, affecting risk assessment and recall procedures upon release.

Concerns summary Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, missing opportunities for earlier specialist assessment.

Concerns summary Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive days.

Concerns summary Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.

Concerns summary There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.

Concerns summary Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time limits or prioritization creates dangerous delays.

Concerns summary There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also deficient, excluding key stakeholders.

Concerns summary Exceptions to patient confidentiality in mental health cases should be considered when informing third parties could provide crucial non-medical support.

Concerns summary Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this potential risk with patients.

Concerns summary Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.

Concerns summary Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen testing for under 5s, creates diagnostic delays.

Concerns summary Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The emergency response was chaotic and staff records were found to be dishonest, indicating severe governance and care failures.

Concerns summary A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.

Concerns summary Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road incidents.

Concerns summary Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road incidents.

Concerns summary There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history in acute and mental health settings.

Concerns summary Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.

Concerns summary The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.

Concerns summary Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.

Concerns summary Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of bag searches during hospital transfers, contributing to her death by overdose.

Concerns summary A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel perforation risk for diverticular disease patients.