2026

Concerns summary There is a significant capacity issue in Cornwall concerning the timely admission and treatment of stroke patients, leading to delays in accessing stroke units.

Concerns summary A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.

Concerns summary Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards unsuitable for their care.

Concerns summary A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.

Concerns summary Nightclub staff delayed calling an ambulance for a critically unwell patron, indicating systemic failures in training and culture regarding medical emergency management.

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 Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and inadequate facilities for appropriate waiting.

Concerns summary Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential conflicts of interest when staff recognise patients outside of personal relationships.

Concerns summary The apparent absence or non-use of an upper alarm setting on bedside oxygen meters risks over-oxygenation, with unclear policies on its implementation or whether it is standard practice.

Concerns summary A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.

Concerns summary Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand consistently outstrips capacity.

Concerns summary Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.

Concerns summary The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate risk register.

Concerns summary Evidence showed the deceased ordered numerous tablets from an individual linked to known addresses, but Essex Police have refused Northamptonshire Police's request to investigate the matter.

Concerns summary Care home staff failed to perform routine blood sugar tests on a diabetic resident, delaying critical diagnosis. A lack of formal shift handovers also prevents timely escalation of deteriorating conditions.

Concerns summary National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.

Concerns summary An agency team leader disregarded clear instructions by providing inappropriate wound care, suggesting inadequate training on care limits and adherence to specialist medical advice for carers.

Concerns summary Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.

Concerns summary The urgent care pathway poorly serves non-immediately life-threatening systemic illnesses, as detailed 111 information is unreliably used by EMAS, families are uninformed of ambulance cancellations, and transfer criteria between services are unclear.

Concerns summary The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.

Concerns summary The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.