2024

Concerns summary Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels and significant vehicle delays at hospitals, likely leading to the deceased's preventable death.

Concerns summary Unawareness among clinicians that they can challenge ambulance call categorisations by untrained handlers, or request a clinical review, can lead to critical delays in dispatch for severe cases.

Concerns summary An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.

Concerns summary Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.

Concerns summary The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision risk, leading to concerns about future deaths.

Concerns summary Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.

Concerns summary Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or monitoring of the significant relapse risks.

Concerns summary The County Hospital in Stafford lacked an essential vascular team, meaning urgent vascular opinions could not be obtained, posing a risk to patient care.

Concerns summary The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.

Concerns summary A GP practice's electronic enquiry system critically failed to log patient information for GP review. Additionally, a persistent hoarse voice was not widely recognized as a laryngeal cancer red flag by healthcare professionals or the public.

Concerns summary A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment application is delaying critical early support, increasing the risk of mental health issues and suicidality.

Concerns summary Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A new suicide risk assessment system lacks clear alerts on medical records, risking clinicians missing vital information.

Concerns summary Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent specialist oversight were significant clinical governance concerns.

Concerns summary There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to extensive waiting times for essential treatment and therapy.

Concerns summary The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients remaining unmonitored for extended periods.

Concerns summary Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS care from Mind, lack robustness and transparency.

Concerns summary The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.

Concerns summary There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.

Concerns summary A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.

Concerns summary There's a lack of understanding in providing first aid for unresponsive patients and insufficient escalation of issues by care assistants, despite new policies not being fully embedded or known.

Concerns summary Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.

Concerns summary Lack of inter-team liaison and specific protocols for liver biopsy on patients with Sickle Cell Disease (HbSS) led to inadequate consideration of their unique needs, including pre-biopsy assessment and post-operative monitoring.

Concerns summary The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.

Concerns summary An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.