2025

Concerns summary A lack of clear communication led to a misunderstanding that a dietetic service treated eating disorders, highlighting a need for clarification that it is not a mental health service.

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.

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.