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Failure to make and document informed prosecution decisions in vulnerable cases 3 11 31 Aug 2022 Unreliable prison keyworker support scheme 5 8 6 Nov 2025 Failure to provide face-to-face clinical assessment when clinically indicated 21 32 14 Jan 2026 Unreliable police handovers of safety-critical information 5 8 23 Jan 2026 Unreliable safety risk assessments for prisoners 10 17 15 Dec 2025 Failure to conduct multidisciplinary risk assessments for high-risk prisoners 2 4 20 Apr 2020 Insufficient critical care bed capacity 4 8 16 Jun 2025 Failure to provide treating clinicians with relevant patient history and baseline information 7 11 30 Jul 2025 Unreliable ACCT suicide and self-harm prevention processes 92 86 29 Jun 2026 Failure to provide timely psychiatric review through home treatment teams 3 4 19 Sep 2019 Unreliable implementation of autism care and support services 8 10 10 Dec 2023 Failure to safely coordinate transfer of urgent surgical patients 5 6 18 Feb 2025 Failure to provide accessible care for people with complex neurodevelopmental needs 4 6 15 Jan 2025 Inconsistent implementation of suicide-prevention systems 8 13 8 Aug 2025 Unreliable coordination and information sharing between primary and secondary care 18 33 23 Sep 2025 Unreliable operation of the Oxevision patient-monitoring system 2 2 8 Feb 2026 Failure to adapt academic decisions and support to student vulnerability 3 4 10 Jul 2024 Insufficient suitable housing for vulnerable young people 2 5 14 Mar 2024 Unreliable arrangements for facilitating prisoner visits 2 7 25 Oct 2024 Unreliable community care-coordinator provision and contact 5 10 25 Sep 2023 Inadequate controls for sodium nitrite poisoning risks 3 4 9 Jul 2025 Unreliable integration of substance misuse services into patient care 15 24 3 Mar 2026 Unreliable social care referral pathways 15 26 30 Jan 2026 Unreliable safety decisions to approve or change offender licence conditions 2 11 29 Nov 2022 Unreliable communication and coordination across maternity care providers 15 21 5 Aug 2025