2025

Concerns summary Poor visibility at a dangerous road junction, caused by overgrown foliage, a dull mirror, and old railings, is exacerbated by an inappropriate national speed limit, posing a risk of future collisions.

Concerns summary The 'Essential Guide to feeding your Baby' is inadequate as it fails to explicitly warn against giving cow's milk to infants under one year due to the risk of anaemia.

Concerns summary Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.

Concerns summary Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety concerns during searches.

Concerns summary A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.

Concerns summary The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety concerns.

Concerns summary Current licensing arrangements for new drivers inadequately address risks from multiple passengers, vehicle loading, and rural road conditions. Insurers also lack consistent methods to identify 'fronting' and effectively communicate telematics-related safety.

Concerns summary A nurse untrained in tracheostomy management was allocated to a unit with high-needs patients, and an agency nurse lacked system login rights, leading to poor documentation and compromised care.

Concerns summary Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions and harm.

Concerns summary The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.

Concerns summary The primary care prescribing regime failed to identify potential addiction and drug-seeking behaviour, and neglected to review medications for ongoing necessity.

Concerns summary Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of available ward beds.

Concerns summary There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.

Concerns summary Lack of guidance for 999 call handlers on 'reasonable enquiries' for missing persons and confusion with the 'Right Care Right Person' initiative led to an inappropriate police response.

Concerns summary Extensive and thick black mould in the property managed by Granddwell Estates poses a significant risk of future deaths.

Concerns summary Numerous streetlights on a dangerous stretch of road were reported faulty but not repaired in a timely manner, severely reducing pedestrian visibility and contributing to fatal collisions.

Concerns summary High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading to insufficient oversight for vulnerable patients.

Concerns summary Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.

Concerns summary Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.

Concerns summary Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.

Concerns summary A dangerous road stretch lacks pedestrian crossings, has obscured visibility from parked vehicles, and suffers from poor street lighting and absent central road markings, leading to multiple incidents.

Concerns summary Inadequate recognition, care planning, and monitoring of malnutrition risks by ward staff, who also failed to follow dietician advice. Auditing processes did not identify these consistent failures.

Concerns summary Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.

Concerns summary Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.