2023

Concerns summary Ofsted's inspection system lacks transparency, negatively impacts school leader welfare, and has insufficient training for managing distress or clear channels for raising concerns. Local authority support also lacks formal policy.

Concerns summary Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a family from seeking assistance during a crisis.

Concerns summary Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.

Concerns summary Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.

Concerns summary Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.

Concerns summary A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.

Concerns summary A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.

Concerns summary Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.

Concerns summary Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was not a formal system, risking future harm.

Concerns summary A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.

Concerns summary A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to an ill-timed operation.

Concerns summary Multiple failures including delayed transfer, confusion over lead clinicians, inadequate pain relief, and critical mismanagement of a nasogastric tube led to a fatal aspiration. The hospital failed to conduct a proper investigation.

Concerns summary Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.

Concerns summary A culture exists where medics may disregard parents' or nurses' views, and junior doctors are not adequately educated when consultants override their decisions, hindering learning.

Concerns summary Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.

Concerns summary Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care needs beyond emergencies.

Concerns summary Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.

Concerns summary A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.

Concerns summary Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.

Concerns summary There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.

Concerns summary National shortages of specialist scanning facilities and delays in the two-week cancer pathway lead to delayed diagnoses and treatments, resulting in poorer patient outcomes and advanced disease.

Concerns summary A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.

Concerns summary A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.

Concerns summary The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.

Concerns summary A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.