2025

Concerns summary Private ambulance staff at a music event lacked adequate training for drug-affected patients and standard equipment, with unclear responsibility for pre-alert calls to hospitals for seriously unwell individuals.

Concerns summary GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.

Concerns summary National regulations for temporary road signage are inadequate, as compliant signage at a collision site was found to be insufficient, indicating a wider safety issue.

Concerns summary The haematology department is severely understaffed and over capacity, leading to insufficient time for comprehensive patient reviews and increasing the risk of future deaths.

Concerns summary The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning Disability Liaison Nurse, leading to poor care.

Concerns summary Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.

Concerns summary Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency care.

Concerns summary Supported accommodation staff had unclear medication supervision roles and failed to communicate critical welfare concerns about a deteriorating resident to the mental health team, hindering proper assessment.

Concerns summary The care home delayed calling an ambulance for an unresponsive resident and maintained inadequate, inaccurate records, including misleading and unlabelled retrospective entries, compromising patient safety.

Concerns summary The Trust's patient safety framework, including incident reporting and mortality review processes, failed to identify and investigate a significant incident, risking future deaths from unaddressed sub-optimal practice.

Concerns summary A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.

Concerns summary Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed cardiac conditions in children.

Concerns summary The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential surgical emergency.

Concerns summary Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities to revise safety packages.

Concerns summary Widely available wide/clawed ferrules for walking sticks lack crucial warnings about potential trip and trapping risks, particularly when used with folding designs.

Concerns summary There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.

Concerns summary Blood gas machines display unrecordably low glucose in a way that can be misinterpreted as an unanalysable sample, potentially delaying appropriate clinical response to critical patient conditions.

Concerns summary A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road layout despite a speed limit reduction, indicating a risk of future deaths.

Concerns summary Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. This systemic issue affects safe patient care and transfers.

Concerns summary The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.

Concerns summary A child requiring 1:1 tracheostomy care died due to inadequate supervision and insufficient staffing, leading to a blocked tracheostomy. This represents a gross failure in care.

Concerns summary The vehicle licensing system relies on older drivers, including those with cognitive decline, to self-report medical conditions. This self-reporting is inadequate and poses a risk of future road deaths.

Concerns summary Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose a risk of future deaths.

Concerns summary Patient observations were not adequately recorded, possibly due to a lack of staff training. Additionally, significant hospital waiting lists and prolonged patient waits for reviews are caused by staffing shortages and insufficient funding.

Concerns summary The practice failed to conduct sufficient long-term review and oversight of a patient's long-term opiate prescription, despite the associated risks, indicating a lack of detailed planning for such patients.