2023

Concerns summary DWP procedures, including lengthy forms, long phone queues, and travel requirements, are impractical and exacerbate symptoms for individuals with mental health illnesses.

Concerns summary The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack of required protective equipment could lead to future deaths.

Concerns summary St. Andrew's Healthcare displayed chronic non-compliance with its pressure ulcer prevention policy, including failures in assessments, daily skin inspections, and incident reporting. This indicates systemic governance and quality assurance deficiencies.

Concerns summary Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for hazards, and failing to provide lifejackets.

Concerns summary A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls highlighting their deteriorating condition.

Concerns summary There is a lack of clarity on responsibility for VTE risk assessments during patient discharge from hospitals to community care, leading to potential gaps where high-risk patients' needs are not met.

Concerns summary The Oxford Trust failed to investigate a patient's death, refused joint efforts, lacked proper meeting records, provided an unreliable statement, and was uncooperative in evidence sharing, hindering learning from the death.

Concerns summary A care home failed to monitor a patient's food/fluid intake and observations, did not call emergency services for a high NEWS2 score, and had incomplete records, with no apparent actions taken after the death.

Concerns summary Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.

Concerns summary The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in record-keeping and communication.

Concerns summary Delays in patients seeing the Tissue Viability Team, specifically due to its unavailability over weekends, put patients at risk of death from pressure ulcers.

Concerns summary Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.

Concerns summary There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for vulnerable individuals.

Concerns summary Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.

Concerns summary Prisons failed to verify and manage critical pre-existing community hospital appointments for prisoners, and lacked fitness-to-transfer assessments, impacting medical care and safety during transfers.

Concerns summary A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.

Concerns summary Surgical procedures for this operation rely on anatomical landmarks without sufficient intra-operative measurement, leading to excessively deep incisions and potential safety risks.

Concerns summary Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.

Concerns summary Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they pose to young children.

Concerns summary Low awareness among primary care professionals regarding key symptoms of a burst aneurysm results in delayed identification and referral, impacting vital early treatment.

Concerns summary The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.

Concerns summary Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.

Concerns summary Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.

Concerns summary The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a rapid access chest pain clinic.

Concerns summary There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately involve or inform the patient's family about his mental health.