2024

Concerns summary Insufficient contingency planning during industrial action led to inadequate medical cover, with one consultant managing 25 patients and the deceased receiving no medical input on a strike day.

Concerns summary A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.

Concerns summary Brightly coloured laundry pods and their sweet-like packaging are confused for food by people with dementia, and easy-to-open packaging increases the risk of accidental ingestion of toxic products.

Concerns summary Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.

Concerns summary A rural, unlit road with a 60 mph limit narrows at a blind bend and bridge, causing frequent collisions. The national speed limit is too high, posing a risk of future deaths.

Concerns summary Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in a new policy increases future risks.

Concerns summary Care agency responders lacked sufficient training to identify a fractured neck of femur, over-relied on patient self-assessment, and inadequately communicated with ambulance services, resulting in a missed diagnosis.

Concerns summary Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between consultants, and lack of awareness of prior admissions or community support.

Concerns summary A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.

Concerns summary DVLA's license re-issue process is flawed due to insufficient gathering of medical history from specialists and GPs, tick-box forms, and lack of verification for self-declarations. This prevents full assessment of applicants' fitness to drive.

Concerns summary Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed suicide/self-harm concerns before release.

Concerns summary Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.

Concerns summary Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer protocols.

Concerns summary The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.

Concerns summary Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.

Concerns summary Agency staff's admitted failure to consistently read care plans jeopardises resident safety by hindering the provision of appropriate and individualised care.

Concerns summary A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to anticipated demand.

Concerns summary Care home staff failed to provide necessary assistance with food and fluid intake and made false care note entries, indicating a systemic failure that jeopardises resident safety.

Concerns summary There are inadequate fire prevention measures for vulnerable, heavy-smoking residents in care settings. Organisations should consult the Fire Service for advice on mitigating risks, such as using metal bins and fire-retardant materials.

Concerns summary The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed this ongoing hazard.

Concerns summary Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies for vulnerable individuals.

Concerns summary Persistent concerns about care quality and unreliable patient notes were noted at Westmorland Court. A registered nurse's failure to perform basic life checks and CPR correctly highlighted training deficiencies and lack of defibrillator availability.

Concerns summary The CAA lacks regulations or guidance for the design, testing, and inspection of amateur-built balloons, and does not regulate competition balloon flying, leaving critical safety aspects unaddressed despite known risks.

Concerns summary A critical Mental Health Treatment Requirement was not transferred or communicated between Trusts, highlighting a systemic failure in MHTR administration and probation oversight.

Concerns summary Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks future deaths as patients may not receive necessary support, leading to crises.