2026

Concerns summary (AI summary) The report identifies limited awareness of salbutamol overuse, inconsistent identification and follow-up of reliever overuse, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.

Concerns summary (AI summary) Inadequate record keeping, poor medication management support, and deficient catheter management were identified in community care services. There were also concerns that training inadequacies had not been addressed.

Concerns summary (AI summary) Incorrect advice was given to a patient upon discharge from West Suffolk Hospital regarding weight bearing and mobilisation, potentially contributing to the development of a DVT; additionally, concerns were raised about ineffective communication processes between hospital staff and patients.

Concerns summary (AI summary) Two incidents at a dialysis centre involved the detachment of a port from a Covidien Palindrome Chronic Dual Lumen Catheter, leading to blood loss; the coroner recommends reporting these events to the Medicines and Healthcare products Regulatory Agency (MHRA) due to concerns about a potential widespread vulnerability.

Concerns summary (AI summary) Nationals of non-designated countries who fail a GB driving test can continue to drive in the UK for up to 12 months on their foreign licence without supervision, despite not meeting the DVSA's safety standards.

Concerns summary (AI summary) The use of the "latching" facility on patient monitoring equipment may contribute to alarm fatigue, making it difficult for staff to respond to different alarms; the manufacturer no longer recommends its use on Emergency Department monitors.

Concerns summary (AI summary) A junior doctor's concerns were ignored by a senior doctor, whose assessment was limited; out-of-hours radiology interpretation was provided by an agency whose expertise was limited to adult radiology, and there were delays in obtaining a scan and intubating the patient.

Concerns summary (AI summary) Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the deceased had also observed leaders using gas equipment in tents previously.

Concerns summary (AI summary) Risk assessments in the care plan were not completed or reviewed with nursing or medical input, and the escalation process for medical input was unclear; also unclear was the system for actioning missing or spent medication.

Concerns summary (AI summary) Falls risk assessments were carried out based on incorrect data, and the Trust lacked a way of auditing their accuracy; a doctor did not appreciate the urgency of the situation after a fall, and the importance of considering anticoagulation reversal medication may be underappreciated.

Concerns summary (AI summary) There was no designated lead with oversight and authority over the deceased's care, and a 'care gap' resulted in fragmented information sharing and updating regarding the deceased's multiple health and drug issues; this was exacerbated by the lack of a simple mechanism to know of wider health and drug misuse issues.

Concerns summary (AI summary) Key issues include a vulnerable cell bell system that can be silenced externally, staff failing to complete critical ACCT documentation, and confusion regarding emergency 'Code Blue' protocols.

Concerns summary (AI summary) Healthcare team, particularly mental health staff, inconsistently attended ACCT reviews, leaving vulnerable prisoners without adequate safety netting and protective measures.

Concerns summary (AI summary) Widespread reliance on inexperienced, probationary prison officers across the prison estate leads to poor communication, lack of control, and increased risk of deaths in custody.

Concerns summary (AI summary) Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.

Concerns summary (AI summary) Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.

Concerns summary (AI summary) Corded telephones in CSU cells pose a clear self-harm risk when suspended, and unreliable provision of telephone access prevents prisoners in crisis from reaching support services.

Concerns summary (AI summary) Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.

Concerns summary (AI summary) GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling habits.

Concerns summary (AI summary) The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for seriously ill drivers.

Concerns summary (AI summary) In-cell automatic fire detection is still to be fully implemented at Eastwood Park prison and across a number of prisons in the wider prison estate; the current use of domestic smoke detectors only mitigates the risks from an in-cell fire.

Concerns summary (AI summary) The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers from understanding urgent risk.

Concerns summary (AI summary) Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after multiple unsuccessful patient contact attempts.

Concerns summary (AI summary) Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.

Concerns summary (AI summary) The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.