2024

Concerns summary A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management opportunities.

Concerns summary Unclear systems for quality checks on unwell residents, limited staff understanding of documentation, and poorly understood escalation procedures for deteriorating patients created significant safety risks.

Concerns summary A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.

Concerns summary The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.

Concerns summary Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient capacity leading to unaddressed obvious vulnerability.

Concerns summary Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, significant wait times for appointments, and poor record-keeping.

Concerns summary Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.

Concerns summary Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.

Concerns summary A lack of child-specific screening tools and NICE guidance for pulmonary thromboembolism in the UK disadvantages clinicians, potentially leading to missed diagnoses and treatment delays in children.

Concerns summary Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the parapet wall remained easily climbable.

Concerns summary A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by poor visibility at night and a lack of adequate warning signs.

Concerns summary Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.

Concerns summary The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.

Concerns summary Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking patient safety.

Concerns summary Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.

Concerns summary A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.

Concerns summary A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent oversight for rectifying systemic issues.

Concerns summary Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the 24-hour period only upon ward admission, despite long patient waits.

Concerns summary Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the baby.

Concerns summary Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.

Concerns summary Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of preventable deaths for patients requiring timely hospital transfer.

Concerns summary A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.

Concerns summary A shared service road dangerously lacks designated pedestrian pathways, clear markings, or warning signs. Obstructions like bins and parked vehicles further reduce visibility and hinder emergency vehicle access.

Concerns summary Concerns arose regarding staff's ability to identify serious incidents during supervised Section 17 leave and the Trust's failure to conduct a proper governance investigation into the incident.

Concerns summary The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient collateral information gathering and inadequate medical attendance, despite family requests.