2025

Concerns summary Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.

Concerns summary The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.

Concerns summary Inadequate and inconsistent recording of patient repositioning, with significant gaps in documentation, suggests patients, especially those at risk of chest infections or pressure damage, are not repositioned as required.

Concerns summary GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.

Concerns summary There were concerns about the suitability of surgical procedures for elderly patients without considering alternatives, and inaccurate handover communications for patients returning from HDU.

Concerns summary The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.

Concerns summary Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, hindering intervention.

Concerns summary Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for vulnerable individuals.

Concerns summary There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.

Concerns summary An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical communication gaps between emergency services.

Concerns summary Inadequate guidance exists for families and carers on how to share concerns or communicate information when a patient, having capacity, withdraws consent for information sharing.

Concerns summary National Highways knowingly delayed replacing hazardous P1 terminal designs for financial reasons, creating an ongoing safety risk for vehicles on designated roads.

Concerns summary Insufficient district nursing staff and increasing patient complexity led to missed appointments and an inability to provide consistent care, despite internal measures to prioritise patients.

Concerns summary Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.

Concerns summary A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by the former estate owners.

Concerns summary A locum doctor discharged a patient without reviewing the complete CT scan report, missing a pulmonary embolism. The Trust cannot confirm all locum doctors receive essential training on reviewing full reports.

Concerns summary Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic collision report.

Concerns summary Pulmonary embolism investigation deviated from NICE guidance; radiology rejected a CTPA without completing a D-dimer test that, if positive, would have necessitated the scan.

Concerns summary Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.

Concerns summary Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.

Concerns summary Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.

Concerns summary A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.

Concerns summary Delayed reporting of road traffic collisions by Police to the Highways Department (annual review vs. immediate) prevents timely identification and intervention for highway safety improvements.

Concerns summary A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.

Concerns summary There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.