2024

Concerns summary Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and joint working protocols between police and mental health services.

Concerns summary A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.

Concerns summary Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.

Concerns summary The patient experienced multiple falls in hospital, with risk assessments completed but no documented falls prevention measures put in place. There was no evidence that steps have been taken to ensure proper documentation and consideration of these measures.

Concerns summary Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in patient discharge from hospitals.

Concerns summary Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.

Concerns summary The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of improvements from an agreed action plan was demonstrated.

Concerns summary An exhausted mother was discharged too soon, only 4 hours post-delivery after a prolonged labour, leading to the baby's death when she fell asleep during breastfeeding. This raises concerns about the timing of postpartum discharges.

Concerns summary A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other similar venues employed them. Concerns exist that lessons about pool safety and the necessity of lifeguards have not been learned.

Concerns summary Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, information sharing between police and mental health services out-of-hours is inadequate, and risks to staff from patients' delusions were not addressed.

Concerns summary A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.

Concerns summary Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is overshadowed by administrative signs. This leads to people underestimating significant risks.

Concerns summary A lift's uncontrolled movement device was unintentionally activated, trapping occupants with no in-lift reset or helpline solution. This caused a significant delay, posing a risk to patients needing urgent care.

Concerns summary Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to escalate urgency upon re-referral.

Concerns summary The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early death.

Concerns summary Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was no feedback loop to clinicians, leaving the family without answers or safety guidance.

Concerns summary A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.

Concerns summary Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the provision of neurology advice and overall patient management.

Concerns summary A specific footbridge, excluded from barrier height improvements implemented on other local bridges, remains a risk for falls onto the motorway. The rationale for this exclusion is unclear.

Concerns summary Inadequate monitoring and documentation of Mr Astley's nutrition and fluid intake led to severe frailty, highlighting systemic failures in care home record-keeping.

Concerns summary Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.

Concerns summary A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.

Concerns summary A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.

Concerns summary Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.

Concerns summary There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral information.