Cornwall and the Isles of Scilly

Concerns summary The absence of mandatory medical checks for drivers over 70, who only self-declare fitness, poses a significant road safety risk. This enables drivers with declining abilities to remain on the road, contributing to fatal and serious collisions.

Concerns summary A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to homelessness or unsuitable placements, increasing supervision difficulties.

Concerns summary A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.

Concerns summary Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety from these systemic failures.

Concerns summary Unaddressed road safety concerns at the collision site, including speed limits and limited visibility for agricultural vehicles, persist due to unimplemented council recommendations.

Concerns summary Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.

Concerns summary A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other similar venues employed them. Concerns exist that lessons about pool safety and the necessity of lifeguards have not been learned.

Concerns summary Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.

Concerns summary Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.

Concerns summary The GP practice lacked a treatment strategy and policies for long-term opioid prescriptions, including warning flags for addiction risk and guidance on co-prescribing opioids with benzodiazepines.

Concerns summary An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness who declined treatment, created significant care gaps.

Concerns summary Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and a two-year waiting list for autism assessments pose significant risks.

Concerns summary Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries despite signs of mental impairment.

Concerns summary Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and exacerbating emergency department overcrowding.

Concerns summary Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving treatment.

Concerns summary An active website provides detailed instructions and direct purchasing links for substances to end one's life, posing a significant risk to vulnerable individuals.

Concerns summary Government policies on lifeguard furlough and lack of advance notice for lockdown relaxation severely hampered RNLI's ability to staff beaches, contributing to drownings due to unpatrolled coastlines.

Concerns summary Persistent severe staffing shortages, bed unavailability, and long waiting lists for psychological treatment in mental health services resulted in inadequate patient screening and care coordination.

Concerns summary A critical omission in patient records and inadequate handover from critical care meant surgical teams were unaware of a prior hypoxic brain injury, leading to an ill-timed operation.

Concerns summary Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff burnout and recruitment difficulties.

Concerns summary Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with patients still waiting over 12 hours in ambulances despite mitigating measures.

Concerns summary Critical pain information was not accurately relayed from reception staff to clinical practitioners, and a need for improved staff training on recognizing and escalating high-risk pain symptoms was identified.

Concerns summary Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.

Concerns summary Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically high levels and warranting review.

Concerns summary Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient care.