Cornwall and the Isles of Scilly

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 Insufficient evidence shows that previously identified hospital failings have been addressed, indicating ongoing risks to patient safety.

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 Healthcare professionals failed to inquire about the contents of 'bottle-fed' milk and did not use interpreters for a non-English speaking mother, reflecting a lack of professional curiosity and adherence to guidance.

Concerns summary Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.

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 steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.

Concerns summary Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.

Concerns summary The hospital lacked clear standard operating procedures and defined pathways for deteriorating renal patients, causing treatment delays and medication errors, despite similar concerns in a previous report.

Concerns summary The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.

Concerns summary The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, and record-keeping was deficient.

Concerns summary A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his mental health issues.

Concerns summary Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, and lacked a clear policy for such situations.

Concerns summary A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, highlighting a failure to support vulnerable individuals and inconsistent council policies on homelessness applications.

Concerns summary Poor nursing care, which likely contributed to the patient's death and poses a risk to others, has not been shown to be addressed or remedied since the incident.

Concerns summary Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency care.

Concerns summary The ambulance service's dispatch system lacks nuance for specific abdominal complaints, leading to an inappropriately low emergency category and delaying critical care for a potential surgical emergency.

Concerns summary Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports from other hospitals.

Concerns summary Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.

Concerns summary Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to significant delays in patient care. The lack of police-to-hospital conveyance options for urgent cases is also a concern.

Concerns summary Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.

Concerns summary Despite repeated observations indicating sepsis and a need for antibiotics, the sepsis six protocol was not triggered due to staff failure and the absence of a digital alert system.

Concerns summary A dangerous stretch of the A38 with a high collision rate lacks funding for a proposed average speed camera safety scheme.

Concerns summary Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort to risky mitigating measures like recommending self-conveyance.

Concerns summary Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a different team and not returning to the operating hospital for essential follow-up.