2024

Concerns summary Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows to open fully and posing a significant fall risk.

Concerns summary Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.

Concerns summary Inconsistent fall risk assessments and care plans, coupled with staff lacking clarity on mitigation, meant high-risk residents were often unsupervised in communal areas or bedrooms, leading to preventable falls.

Concerns summary A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support and patients falling through service gaps.

Concerns summary Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response and oversight, failing to provide timely assistance.

Concerns summary Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.

Concerns summary A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery of prescribed medication and the accuracy of medical records.

Concerns summary Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular disease or use of risk-based stratification, omitting vital health indicators.

Concerns summary The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.

Concerns summary The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information being disseminated to GPs.

Concerns summary Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.

Concerns summary Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.

Concerns summary GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future deaths.

Concerns summary A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying legal frameworks for individuals with chronic alcohol dependence, risking their protection.

Concerns summary An overwhelmed emergency department with insufficient staff, coupled with staff's failure to recognize sepsis symptoms and critical low blood pressure, compromised patient safety.

Concerns summary The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.

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.