2023

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 Police guidance for pre-release checks in domestic abuse cases was not fully applied, and officers felt they lacked legal power to retain a suspect's house key.

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 Dangerous polypharmacy involving escalating doses of synergistic pain medications led to central respiratory depression, exacerbated by difficulties for GPs in managing drug dependency and a lack of proactive medication review protocols.

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 A critical failure to provide a case manager or key worker for autistic young people, as per NICE guidance, limits access to support services and prevents navigation of care pathways.

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 Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and safety regulations, and their proximity to stairs poses a significant risk.

Concerns summary Non-functional lights on a pedestrian refuge, including an illuminated bollard and streetlamp, create a significant danger for both road users and pedestrians.

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 An inaccurate DBS certificate failed to disclose a violent conviction, enabling an individual to be employed with access to firearms. The source of this critical error is currently unclear.

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.