2023

Concerns summary Critical delays in transferring patients from ambulances to the emergency department are caused by hospital bed shortages, leading to insufficient patient monitoring and significant ambulance handover delays.

Concerns summary Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust morbidity review after the patient's death.

Concerns summary Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, and incorrect single access permissions, allowing unauthorized access to weapons.

Concerns summary The death of an individual with depression and psychosis by suicide highlights potential concerns regarding the adequacy of mental health support and intervention.

Concerns summary Inadequate training and assessment processes failed to ensure doctors, especially those trained overseas, were familiar with Royal College guidance for returning ED patients and investigating neurological findings like subarachnoid haemorrhage, with learning not effectively embedded.

Concerns summary Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.

Concerns summary Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.

Concerns summary Hospital overcrowding and delays in transferring patients from ambulances to the emergency department led to inadequate safety checks and delayed diagnosis of severe injuries.