2024

Concerns summary Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could hinder their discharge process.

Concerns summary Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create a continued risk of future deaths.

Concerns summary There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.

Concerns summary The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.

Concerns summary Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent support.

Concerns summary Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.

Concerns summary Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.

Concerns summary Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.

Concerns summary Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health Act patients, compounded by insufficient police powers to intervene for public safety.

Concerns summary Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk assessment and delegation during patient transfers.

Concerns summary There is a critical lack of specific medical and official guidance regarding the fatal risks associated with combining clozapine with alcohol.

Concerns summary Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical safety recommendations remain outstanding or delayed.

Concerns summary Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from combined medications.

Concerns summary Poor understanding and recognition of Avoidant Restrictive Food Intake Disorder (ARFID) among professionals, coupled with inadequate cross-sector strategies and non-holistic care planning, increased risks for vulnerable children.

Concerns summary DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of existing support tools.

Concerns summary A known accident black spot, exacerbated by uninvestigated water sources on the road, alongside Wessex Water's failure to log and act on reported leaks, poses a significant ongoing risk of icy road conditions.

Concerns summary Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak Up and Speak Out' principles in emergency situations.

Concerns summary Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.

Concerns summary A lack of national guidance exists for children with persistent symptoms of swallowed non-radio-opaque foreign objects, specifically regarding the need for endoscopy after negative initial imaging.

Concerns summary Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a missed opportunity to administer a potentially life-saving antidote.

Concerns summary Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult social care for care leavers. Deficiencies in risk assessment standards and non-mandatory Mental Capacity Act training persist.

Concerns summary Pharmacies lack a direct and obligated reporting system to inform Recovery Steps when service users stop collecting methadone or when wider welfare concerns arise, risking vulnerable individuals missing essential support.

Concerns summary Inadequate liaison between Adult Social Care and care providers regarding service-users' fluctuating capacity risks missed care opportunities for vulnerable individuals.

Concerns summary Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.

Concerns summary Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to recognize deterioration or feeling unable to re-contact emergency services, missing critical reassessment opportunities.