2025

Concerns summary Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.

Concerns summary Hospital reviews of unusual cardiac deaths are not sufficiently shared across specialties, and patients with cardiac and rheumatological conditions are inadequately assessed for associated risks.

Concerns summary Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.

Concerns summary Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the detainee adequately.

Concerns summary Emergency staff showed no improved ability to respond to cardiac arrest. Medical staff lacked understanding of prolonged QTc syndrome and a robust process for its investigation and referral.

Concerns summary Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs cannot be fully met, posing a risk of death.

Concerns summary The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components for S.117 plans.

Concerns summary A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This specific scenario of tyre detachment is not accounted for in industry testing, affecting many vehicles.

Concerns summary The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This prevented a critical review of overdose risks and potential adjustments to prescribing practices.

Concerns summary Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing levels may be insufficient to manage these challenges.

Concerns summary The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.

Concerns summary A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for appointments or initial assessments.

Concerns summary Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent search was also potentially inadequate.

Concerns summary Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic checks.

Concerns summary Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring also meant deterioration was missed, losing intervention opportunities.

Concerns summary A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, risking delayed care and missed links to mental health decline.

Concerns summary Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen and delays in escalating a deteriorating patient's condition.

Concerns summary Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.

Concerns summary Poor documentation, incomplete falls risk assessments, and staff misunderstanding of the falls policy for anticoagulated patients led to inadequate care and missed medical advice.

Concerns summary Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.

Concerns summary A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in essential follow-up.

Concerns summary No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.

Concerns summary Drivers are failing to self-notify the DVLA of medical conditions, and there's a lack of clarity on medical professionals' awareness or effective use of reporting guidelines. A promised national road safety strategy addressing this issue remains unpublished.

Concerns summary Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling and timely response to basic needs, causing distress.

Concerns summary Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.