2026

Concerns summary Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.

Concerns summary Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.

Concerns summary Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.

Concerns summary An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.

Concerns summary Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.

Concerns summary The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.

Concerns summary The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.

Concerns summary The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.

Concerns summary Concerns remain regarding poor record keeping and inadequate compliance with care plans, which pose a risk to future patient safety.

Concerns summary The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health information regarding these risks.

Concerns summary Inadequate pain management, lack of nutritional support, and severe neglect of a pressure sore, exacerbated by nursing staff ignoring carers' concerns, led to significant deterioration.

Concerns summary Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on the system used.