2024

Concerns summary A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes for admission, led to a denied hospitalisation.

Concerns summary There is a critical lack of clear public and professional safety guidance regarding the positioning and use of baby carriers/slings, particularly for breastfeeding, putting infants at risk of suffocation.

Concerns summary The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe helicopter operations.

Concerns summary A split Hickman Catheter, posing a significant infection risk, was not removed promptly despite advice and was not reported via the Trust's Datix system as required by protocol.

Concerns summary There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and documentation standards.

Concerns summary Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear evidence of deteriorating capacity.

Concerns summary Estate agents lack industry standards or guidance for informing tenants about property hazards, such as unsafe accessible flat roofs, and failed to follow up on prior complaints.

Concerns summary Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a defibrillator, compromising emergency response capabilities for residents.

Concerns summary Care staff lacked protocols to prevent administering anticoagulant medication to clients who had fallen, due to an inability to identify contraindications without medical oversight.

Concerns summary Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort to risky mitigating measures like recommending self-conveyance.

Concerns summary Repeated last-minute surgery cancellations are occurring due to insufficient theatre capacity. Despite prioritization reviews, a lack of theatre expansion means this systemic issue risks future deaths.

Concerns summary The GP practice failed to follow lower limb wound care frameworks, escalate concerns, or support patient self-management. Furthermore, it lacked adequate systems for internal investigation of patient safety incidents.

Concerns summary Care staff lacked consistent understanding and training on supervising a high-choking-risk resident, expressed low confidence in emergency first aid, and failed to apply professional curiosity.

Concerns summary The public is largely unaware of the life-threatening fire risks posed by lithium-ion batteries from electronic devices stored in homes. There is a critical lack of communication and media coverage on this danger.

Concerns summary A significant surgical complication was not recorded in the operation note, meaning other staff were unaware. Furthermore, the official investigation failed to address this key issue, hindering learning from deaths.

Concerns summary There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.

Concerns summary Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and inconsistent risk assessment methodology.

Concerns summary Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed roads. This creates significant pedestrian safety risks, especially for those with luggage.

Concerns summary The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, inadequate supervision, and substandard note-keeping, risking sub-optimal care for vulnerable individuals.

Concerns summary Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new clinical settings.

Concerns summary HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a specific ligature point was identified in Residential Unit 3.

Concerns summary Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments for unaccepted patients are not audited, creating a safety net gap.

Concerns summary Inadequate road signage at a busy roundabout, especially for lane usage and alternative pedestrian/cyclist routes, makes navigation difficult for unfamiliar drivers and cyclists, risking collisions.

Concerns summary Insufficient professional curiosity, "falsely reassuring" notes, and failure to escalate a patient's decline by clinicians led to a lack of consultant involvement over a weekend. Poor record-keeping and absence of an internal investigation were also identified.

Concerns summary There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.