2025

Concerns summary Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns about potential recurrence.

Concerns summary A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.

Concerns summary Concerns exist about the fatal cardiac side effects of Elvanse, especially with remote prescribing relying on potentially unreliable patient-reported observations and verbal advice that ADHD patients may forget.

Concerns summary A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, hindering timely mental health assessment.

Concerns summary The unregulated online sale of substandard lithium-ion batteries for e-bikes poses a significant fire risk, with online marketplaces currently disclaiming safety responsibility. This highlights the need for stronger regulations and public awareness.

Concerns summary Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation protocols, compounded by consultant oversight.

Concerns summary Critical renal findings were not communicated to spinal surgeons, resulting in spinal surgery being inappropriately performed before a necessary renal procedure. Subsequently, no formal investigation or learning review occurred for eight months.

Concerns summary The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are insufficient to embed these critical safety practices.

Concerns summary A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and were inadequately trained in risk assessments and care plan creation.

Concerns summary Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.

Concerns summary Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.

Concerns summary The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays and inappropriate treatment.

Concerns summary A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital environment.

Concerns summary A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of an external warning label obscured safe usage requirements from users.

Concerns summary There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies during acute medical emergencies in prison.

Concerns summary There were inadequate Speech and Language Therapy assessments, significant gaps in staff training for Basic Life Support, first aid, and nutritional assessments, and catering staff were unaware of resident dietary restrictions, posing risks to resident safety.

Concerns summary The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear responses during medical emergencies and conveyance.

Concerns summary Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.

Concerns summary A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.

Concerns summary The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.

Concerns summary Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.

Concerns summary Inadequate lighting on railway tracks and trains makes it difficult to locate trespassers at night, meaning current safety provisions are insufficient and increase the risk of collision.

Concerns summary Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.

Concerns summary Insufficient staffing levels in care settings, especially when staff are distracted, compromise resident safety by reducing direct supervision.

Concerns summary Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.