2025

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.

Concerns summary Poor documentation of an unwitnessed fall, delayed medical attention despite clear patient deterioration, and inadequate staff training contributed to missed opportunities for care.

Concerns summary The Trust failed to investigate the progression of a severe leg wound under district nurse care, and a recommended orthopaedic follow-up from an Emergency Department visit was not actioned.

Concerns summary Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.

Concerns summary The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.

Concerns summary A GP failed to perform a basic vascular examination for a patient presenting with a foot wound and leg pain, contrary to national guidelines and posing a risk to future patients.

Concerns summary There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering patient care.

Concerns summary A paramedic misinterpreted a ReSPECT form, believing it precluded resuscitation for choking, which may be a reversible event, raising concerns about form application.

Concerns summary Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.

Concerns summary There were systemic failures in documentation and adherence to Trust policy regarding falls assessment, prevention measures, timely medical reviews, and family communication following a patient fall.

Concerns summary There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.

Concerns summary The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.

Concerns summary Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.

Concerns summary Whipps Cross A&E experiences severe overcrowding, inadequate staffing, and insufficient resuscitation beds, leading to critically ill patients receiving substandard care in corridors or less equipped areas.

Concerns summary Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or control usage, despite revised policies.

Concerns summary Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.

Concerns summary The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.

Concerns summary Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual hospital capacity.

Concerns summary No system prevents staff non-compliant with mandatory training, including basic life support, from working on inpatient wards, posing a particular risk to vulnerable elderly patients.

Concerns summary Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.