2025

Concerns summary There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.

Concerns summary Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.

Concerns summary The 60mph speed limit on the stretch of Sarratt Road between the M25 over-bridge and Sarratt Village is too high, posing a road safety risk.

Concerns summary West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.

Concerns summary A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.

Concerns summary A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable child placement.

Concerns summary Care agencies lack a clear triage algorithm for non-medical call handlers and carers cannot perform basic observations, hindering effective client monitoring and response to illness.

Concerns summary The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without adequate guidance.

Concerns summary A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.

Concerns summary Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to unaddressed issues.

Concerns summary There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.

Concerns summary Dangerous road conditions, including ungritted ice and flowing water, were not addressed despite public reports. The existing reporting systems for road faults were unclear and disparate, leading to a failure to act on these critical safety concerns.

Concerns summary Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric care.

Concerns summary A lack of trained ward doctors for lumbar punctures and the absence of a formal escalation pathway for assistance created significant delays in crucial diagnostic testing.

Concerns summary A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were taken to address these systemic gaps.

Concerns summary There was a lack of staff training for hard collar fitting and poor communication between clinicians, leading to insufficient consideration of treatment options and risks, preventing informed patient decisions.

Concerns summary Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.

Concerns summary Tesco staff, including duty managers, lacked basic first aid and CPR training, resulting in a failure to recognize cardiac arrest, perform life-saving actions, or effectively communicate crucial information to emergency services.

Concerns summary Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, risking patient harm.

Concerns summary Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and decision-making.

Concerns summary Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.

Concerns summary Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.

Concerns summary There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.

Concerns summary An unnecessary hospital admission and inadequate district nursing care for a pressure sore, compounded by a lack of organizational reflection, led to preventable harm in an elderly patient.

Concerns summary An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's pulmonary risks in the elderly.