2023

Concerns summary Inconsistent 999 call procedures and inadequate nurse training for chest pain emergencies, coupled with low awareness of critical conditions like Dissecting Aortic Aneurysm, led to fatal delays.

Concerns summary A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.

Concerns summary The lack of regulation for counsellors in England and Wales, including no requirements for training, record-keeping, or reporting of self-harm risks, poses a significant risk of future deaths.

Concerns summary A patient remained in an unsuitable acute hospital due to a lack of care beds. Poor information sharing between authorities also failed to recognize a safeguarding risk, endangering residents and staff.

Concerns summary Significant and prolonged NHS waiting times for gastroenterology and gynaecology referrals post-Covid are causing distress, delaying diagnoses, and impeding crucial treatment for patients with severe conditions.

Concerns summary A chronic national shortage of Paediatric Pathologists causes significant delays in reports, hindering timely genetic testing for families and preventing future deaths. Greater use of molecular autopsy is needed.

Concerns summary Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.

Concerns summary Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a critically delayed radiological report.

Concerns summary Patients with acute, severe skin conditions are at risk from not receiving consultant dermatology input and biopsy within 24 hours, or continuous consultant oversight throughout their inpatient stay.

Concerns summary Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to inaccessible communication, and inadequate assessment of participant swimming ability or fitness.

Concerns summary A lack of available and suitable emergency social care placements forced a patient into a detrimental acute hospital stay, leading to rapid deterioration, highlighting systemic social care shortages.

Concerns summary Undersized sensory mats next to beds fail to detect patient movement if they fall outside the mat's small coverage area, risking undetected falls and potential non-compliance with manufacturer instructions.

Concerns summary There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to his death.

Concerns summary The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.

Concerns summary School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation processes and poor communication between the school and external providers.

Concerns summary Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.

Concerns summary Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.

Concerns summary UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea swimming and snorkelling in unfamiliar locations with strong currents.

Concerns summary Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of eating disorders, risking unaddressed, urgent medical needs for vulnerable service users.

Concerns summary The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.

Concerns summary There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk of further self-inflicted deaths.

Concerns summary A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.

Concerns summary Concerns exist regarding the lack of clear government advice to schools on seatbelt use in commuter coaches and insufficient public information campaigns promoting seatbelt safety for children.

Concerns summary Inadequate clinical record keeping and a failure to perform falls risk assessments, compounded by staff not properly reviewing patient records, suggests a systemic culture of indifference within the Trust.

Concerns summary There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.