2024

Concerns summary Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him to misuse it for self-harm without scrutiny.

Concerns summary The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.

Concerns summary Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests highlighting similar electrolyte monitoring failures.

Concerns summary NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.

Concerns summary A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as a driver would repeat leaving a passenger in an unsafe location and police contact protocols were not followed.

Concerns summary Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney transplant patients.

Concerns summary A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.

Concerns summary Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.

Concerns summary Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious complications like pneumonia and pressure damage, exacerbated by the absence of an out-of-hours falls service.

Concerns summary There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack sufficient understanding of available housing options and appropriate release planning.

Concerns summary Royal College of Pathologists' guidelines for urgent LFT reporting have inappropriate thresholds for pregnant women, leading to delayed diagnosis and treatment of conditions like Acute Fatty Liver of Pregnancy.

Concerns summary Multiple doctors failed to diagnose appendicitis in a child. Concerns include a lack of readily available bedside ultrasound and inadequate medical training in considering this diagnosis for abdominal pain.

Concerns summary Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug found originated from their facility.

Concerns summary A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.

Concerns summary There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.

Concerns summary A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' is linked to a lack of trust in formal reporting mechanisms.

Concerns summary Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.

Concerns summary Residents unsafely climb onto balconies to clear blocked drainpipes, posing a fall risk. The absence of remedial works means this dangerous practice is likely to continue.

Concerns summary Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing severe, life-changing health problems like urological and liver damage.

Concerns summary There is no national guidance for primary care clinicians to assess prolonging anti-coagulation for immobile elderly patients post-discharge, leaving them at risk of fatal DVT.

Concerns summary A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to homelessness or unsuitable placements, increasing supervision difficulties.

Concerns summary A dangerous uncontrolled pedestrian crossing on a multi-lane 40mph road lacks safety features and has a history of accidents. Redesign plans are uncertain and significantly delayed.

Concerns summary There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.

Concerns summary A dangerously narrow shared-use path is heavily used by fast-moving cyclists and pedestrians, leading to accidents. Its width is well below national guidance, and no clear safety solution has been implemented.

Concerns summary The Safeguarding Adult Review following a patient's death was of poor quality, lacking proper investigation, documentation, and family input. This failure hinders learning and prevention of future deaths.