2024

Concerns summary The ACU's generic, pre-populated risk assessment for grass-track events and the lack of a mandatory event-specific safety plan for Club/National events create a significant risk of future deaths.

Concerns summary Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.

Concerns summary Insufficient paediatric nursing staff, inadequate documentation and action planning during handovers, and a non-robust system for recognizing acutely ill babies in ED compromise patient safety.

Concerns summary Insufficient paediatric nurses, poor recognition of patient severity, inadequate PEWS escalation to senior doctors, and ineffective medical handover documentation compromised care in the Emergency Department.

Concerns summary Lengthy neurology waiting times, absence of mandatory annual GP epilepsy reviews, lack of clear national guidance for long-term monitoring, and poor communication of critical post-discharge information risk patient safety.

Concerns summary A lack of automatic cardiology referral procedures led to sub-optimal cardiac failure management, and poor inter-departmental communication caused delayed and uncoordinated wound care.

Concerns summary Poor and inconsistent record keeping on a frailty unit, including lack of documentation for patient behaviour and professional assessments, prevented effective management and communication. There was also no system for agency staff to access policies.

Concerns summary A national shortage of Consultant Histopathologists resulted in an NHS Trust being unable to provide one for MDT meetings, leading to an incorrect cancer diagnosis. This poses a significant widespread risk to patients.

Concerns summary Clinicians and practitioners involved in mental health inpatient discharge lack adequate training in the discharge process, particularly concerning complex issues arising from out-of-area admissions.

Concerns summary Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.

Concerns summary Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, as a failure to refer for cancellation contributed to despair and death.

Concerns summary Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures for investigating and assessing risks following catastrophic incidents in social housing.

Concerns summary Police officers lack sufficient training to recognise drug intoxication, overdose, mental health conditions, and the heightened risk of positional asphyxia in detainees. There's also no mandatory refresher training for constant observations.

Concerns summary There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and operation of the Adult Critical Care Service Cymru for urgent patient transfers.

Concerns summary Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries despite signs of mental impairment.

Concerns summary There is currently no established adult care pathway, transition protocol from childhood to adulthood, or effective review process for patients with hydrocephalus shunts, risking fatal outcomes.

Concerns summary A system flaw allowed a patient to submit concerning questionnaire responses after cancelling an appointment, but there was no protocol to alert clinicians to review these urgent responses outside the standard timeframe.

Concerns summary Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and exacerbating emergency department overcrowding.

Concerns summary Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also communication failures, insufficient telephone support, and an ongoing national mental health bed shortage.

Concerns summary Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving treatment.

Concerns summary The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack of thorough investigation and learning.

Concerns summary Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little meaningful reflection or remediation followed her death.

Concerns summary The transfer of critical information was inefficient, posing risks to patient care.

Concerns summary Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a previous coroner's intervention.

Concerns summary Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for complex patient needs. Staff were also fatigued and felt unable to raise concerns.