2025

Concerns summary No clear evidence exists that risks of fatal harm on railway tracks have been mitigated, with recommended detection technology unimplemented and training effectiveness for train operators and station staff unproven.

Concerns summary There is a complete absence of regulation for Non-Therapeutic Male Circumcisions, including no requirements for training, accreditation, consent, record-keeping, infection control, or crucial aftercare.

Concerns summary The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.

Concerns summary No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety risks.

Concerns summary Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's mental health.

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 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 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.

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 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 The lack of speed enforcement on a specific A3083 road stretch has contributed to multiple fatal collisions caused by excessive speeding.

Concerns summary The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.

Concerns summary The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.

Concerns summary The MOD's vehicle maintenance system (JAMES) is complex, lacks audit capabilities, and has no formal processes for inspecting, testing, or providing feedback on repairs, risking vehicle safety.

Concerns summary A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.

Concerns summary Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency departments were identified.

Concerns summary A high-risk falls patient was discharged home before a careline pendant was confirmed as installed, with conflicting records on its provision, raising concerns about safety post-discharge.

Concerns summary Mortuaries demonstrate an under-appreciation of formalin dangers, lacking routine monitoring and appropriate equipment for handling highly contaminated repatriated bodies, exposing staff to severe health risks.

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 An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and increases the risk of future drug-related deaths.

Concerns summary Failures in a walk-in centre to escalate abnormal vital signs, conduct structured risk assessments for pulmonary embolism, and properly apply clinical decision tools indicate a lack of clear protocols and training.

Concerns summary A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for vulnerable individuals.

Concerns summary The ambulance triage system's rigidity incorrectly categorised a heart attack call as less urgent, lacking specific determinants for heart attack symptoms and risking delayed response if a cardiac arrest occurs.

Concerns summary Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.

Concerns summary Inconsistent national guidance for autism diagnosis hindered specialist dietician referrals for ARFID, while the insensitive Capillary Refill Time test provided misleading reassurance regarding dehydration in children.