2025

Concerns summary Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed diagnosis.

Concerns summary Cannabinoid vape users are unaware of the significant and variable risk of nitazene adulteration in vaping fluids and lack access to Naloxone, posing a high overdose risk.

Concerns summary Insufficient on-call perfusionist staffing during simultaneous emergency surgeries, not meeting safety guidelines, risks delays in identifying critical issues during cardiopulmonary bypass procedures.

Concerns summary Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication compliance, contributed to mental health deterioration.

Concerns summary Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.

Concerns summary The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential investigation requirements.

Concerns summary Inadequate resources have led to significantly prolonged waiting times for cardiac surgery after angiography, consistently exceeding national targets and increasing to 17 days.

Concerns summary A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.

Concerns summary Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for state participation and final report timelines.

Concerns summary The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an ongoing risk.

Concerns summary The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.

Concerns summary Insufficient radiologists led to a critical abnormality (aortic dissection) being missed on a CT scan, with current staffing levels still below guidelines, posing a risk of future deaths.

Concerns summary Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.

Concerns summary Maternity services are unequally split with limited support and no on-site paediatric cover at one site. Concerns also include ambiguous unit classification and non-standardised guidelines for the LISA procedure and newborn cardiac arrest causes.

Concerns summary The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from high places when housing him on the sixth floor.

Concerns summary A mound of earth on the motorway central reservation creates a dangerous hazard, causing loss of vehicle control and risking catastrophic accidents for road users.

Concerns summary Lancashire lacks a 24/7 thrombectomy service and a clear plan for its delivery, compounded by non-stroke specialists' misunderstanding of service availability and a lack of regional mutual aid.

Concerns summary Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for insulin-dependent prisoners.

Concerns summary The design and safety supervision of helicopters are concerning, specifically regarding the inadequate provision of system and flight-testing data from aircraft manufacturers to suppliers for assessing critical components.

Concerns summary Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.

Concerns summary The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.

Concerns summary The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, and record-keeping was deficient.

Concerns summary Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely jeopardizing lives.

Concerns summary Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.

Concerns summary Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of professional curiosity and poor record-keeping also contributed.