2025

Concerns summary A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his mental health issues.

Concerns summary Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, and lacked a clear policy for such situations.

Concerns summary A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, highlighting a failure to support vulnerable individuals and inconsistent council policies on homelessness applications.

Concerns summary Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.

Concerns summary Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.

Concerns summary A&E had excessive waiting times and lacked timely medical triage, risking critical patient deterioration. Follow-up calls were made without full clinical information or clear advice, and essential patient results were not sent to the GP due to staff unfamiliarity with the process.

Concerns summary Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.

Concerns summary Inadequate falls risk assessments, poor documentation, and infrequent observations for a deteriorating patient were compounded by unsafe side-room placement and severe understaffing.

Concerns summary The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit authorization decisions.

Concerns summary The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future learning and policy development.

Concerns summary The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.

Concerns summary Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.

Concerns summary During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.

Concerns summary Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.

Concerns summary Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.

Concerns summary The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.

Concerns summary Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.

Concerns summary Hospital patient information on induction was incomplete regarding risks of prolonged pregnancy, and midwives showed inconsistent understanding of escalating concerns for labouring mothers and CTG traces.