2024

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 Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, mental health staff lacked training on managing service users who decline critical 72-hour review meetings.

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 Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite a history of self-harm and deteriorating mental state contributed to the death of a vulnerable adult.

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.

Concerns summary The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.

Concerns summary Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of complications.

Concerns summary Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.

Concerns summary The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.

Concerns summary The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.

Concerns summary An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.

Concerns summary A lack of policy governing interaction between the Council and Stockport Homes means urgent equipment requests and repairs are not reviewed, risking delays and uncompleted works.