2025

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.

Concerns summary A residential cul-de-sac lacks adequate barriers and standard height kerbing at its end, allowing vehicles to repeatedly enter an adjacent canal, posing a significant safety risk.

Concerns summary A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.

Concerns summary Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.

Concerns summary No clear system exists to determine ownership and responsibility for shipwrecks accessible to the public, resulting in a lack of essential warning signage and an inability to address safety concerns.

Concerns summary Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.

Concerns summary The hospital's death investigation process is dysfunctional, characterized by delayed meetings, poor record-keeping, slow escalation, and unreliable medical record provision. Concerns about a specific surgeon also remain unaddressed.

Concerns summary A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks overlooking critical objective indicators.

Concerns summary Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.

Concerns summary Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. Planned speed reductions may not fully mitigate this.

Concerns summary The driving licence system's reliance on self-reporting medical conditions, particularly dementia, is unsafe due to significant underreporting. This exposes other road users to substantial risk from drivers with compromised abilities.

Concerns summary The UK's driver licensing system has lax visual acuity checks, relying on flawed self-reporting over decades. This enables drivers with impaired vision to obtain licenses through deception, creating a significant road safety risk.

Concerns summary Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and auditing to prevent such systemic failures, risking future harm.

Concerns summary A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.

Concerns summary UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe transfer and treatment.