2025

Concerns summary Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to fully enter the room, prolonging emergency response for a distressed student.

Concerns summary Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.

Concerns summary Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.

Concerns summary A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed ladder, unlike the securely fenced westbound side.

Concerns summary Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially treated bacterial endocarditis.

Concerns summary Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.

Concerns summary A nationwide medical equipment supplier caused significant delays and provided defective equipment, including an incorrect pump for a turning system, leading to suboptimal patient care and prolonged immobility.

Concerns summary Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.

Concerns summary Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also led to missed patient risk factors.

Concerns summary A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.

Concerns summary Many mobility scooters, especially older models, lack a crucial secondary hand brake system, creating significant safety risks for riders and the public. Guidelines need reviewing.

Concerns summary There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.

Concerns summary There are no legal restrictions on newly qualified drivers carrying multiple young passengers, which increases collision risk and warrants a review of current provisions.

Concerns summary Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine maintenance procedures also fail to identify component wear and tear.

Concerns summary Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student halls of residence.

Concerns summary A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a vulnerable patient.

Concerns summary Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.

Concerns summary Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.

Concerns summary The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.

Concerns summary GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.

Concerns summary A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is unsafe and requires permanent reduction.

Concerns summary The 30 mph speed limit on A361 North Bar Street is potentially too high. A road rise obscures the pedestrian crossing, increasing collision risk, especially given high pedestrian traffic.

Concerns summary The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.

Concerns summary Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.

Concerns summary There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.