Cornwall and the Isles of Scilly

Concerns summary Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing essential contact.

Concerns summary Private mental health locked rehabilitation units lack a national framework for referral response times, potentially leaving patients on inappropriate wards and risking their safety.

Concerns summary Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.

Concerns summary Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.

Concerns summary A critical risk of respiratory depression in opioid-treated patients receiving nerve blocks was not widely recognised, and national monitoring guidelines were absent. This necessitates new guidelines and professional awareness.

Concerns summary Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for national guidelines to ensure consistent, timely treatment.

Concerns summary Limited DVLA mechanisms exist for medically reviewing drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to drivers withholding information. Vehicle modification relevance also goes unchecked.

Concerns summary Limited DVLA mechanisms exist for medically reviewing elderly drivers with deteriorating health, and GPs face conflicts of interest in reporting, potentially leading to patients withholding crucial medical information to retain licenses.

Concerns summary A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from accepting crucial preventative treatments.

Concerns summary The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet use, creating an unsafe environment.

Concerns summary The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.

Concerns summary Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.

Concerns summary Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.

Concerns summary Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island residents.

Concerns summary Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital treatments.

Concerns summary National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.

Concerns summary Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident scene and increased risk of death.

Concerns summary Failure to routinely use respiratory rate benchmarks, oxygen blood monitoring, and recognise critical red markers in paediatric respiratory medicine hindered diagnosis and treatment.

Concerns summary Systemic failings included significant delays in labour assessment, inadequate routine physiological observations, lack of standard equipment for community midwives, and inappropriate triage of a critical helpline call, leading to sepsis being overlooked.

Concerns summary Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk patients.

Concerns summary The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a persistent risk of vehicles leaving the road.

Concerns summary Lack of adequate lighting at the harbour wall end and a single, hard-to-spot lifebelt created significant safety risks for visitors.

Concerns summary Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.

Concerns summary The increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.