Plymouth, Torbay and South Devon

Concerns summary Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account for mental health vulnerabilities.

Concerns summary Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing person reports.

Concerns summary The Trust showed a lack of staff training in escalating serious clinical incidents, no effective process for reviewing notes to identify issues, and confusion about Serious Incident Report procedures.

Concerns summary The care home failed to conduct regular blood tests, inadequately managed infections, and lacked clear policies for medical escalation, capacity assessment, and documentation, despite patient needs exceeding capacity.

Concerns summary Two distinct triage systems for 999 and 111 calls create a two-tiered ambulance categorisation for similar urgent breathing complications, potentially delaying critical responses based on the system used.

Concerns summary Police processes failed to notify the Firearms Licensing Department of a prosecution, and the department did not check PNC records, leading to a shotgun being returned to a prohibited individual.

Concerns summary An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information to the Coroner.

Concerns summary Critical delays in performing a Caesarean section were caused by significant communication failures among staff, inadequate training on recognising abnormal foetal movements, and poor escalation protocols, compounded by consultant oversight.

Concerns summary There is a critical gap in the availability of the time-sensitive thrombectomy procedure for severe stroke patients across the South West region.

Concerns summary Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.

Concerns summary A hospital's investigation wrongly deemed a fatal patient-on-patient assault unforeseeable, despite ignoring prior violent incidents and failing to implement required enhanced observations for a high-risk patient.

Concerns summary Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by untimely follow-up appointments and inappropriate discharge decisions for a progressing infection.

Concerns summary A significant gap in care exists for autistic individuals in crisis without a treatable mental health condition, and the Special Allocation Scheme failed to address an autistic patient's specific needs.

Concerns summary Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for this cardiotoxic drug.

Concerns summary The absence of a real-time database for hospital helicopter landing sites and a lack of readily available manager contact details present significant risks to safe helicopter operations.

Concerns summary A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.

Concerns summary Hospital care failures led to sepsis from pressure sores, a UTI, and pneumonia. Concerns include inadequate skin checks, risk assessments, malnutrition screening, patient repositioning, and lack of follow-up or photographic documentation for wound care.

Concerns summary Mature trees lining Embankment Road are dangerously close to the carriageway, directly contributing to multiple fatal collisions when vehicles leave the road. Their placement also obstructs pedestrian safety.

Concerns summary There is a critical lack of specialist healthcare provision and funding for research into severe Myalgic Encephalomyelitis (ME). Limited doctor training and inadequate NICE guideline details on managing severe ME are also significant concerns.

Concerns summary The car's gear selection design, lacking an intermediary step beyond a button press, contributed to driver error, raising concerns about vehicle safety features.

Concerns summary The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and Barring Service referral regarding actions of a former manager received no response.

Concerns summary Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding a prisoner's anxiety and medication was missing, contributing to their death.

Concerns summary Independent mental health assessors lack mandated access to full patient records, while staff misunderstand voluntary admission and the "least restrictive option," potentially hindering appropriate care.

Concerns summary Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.

Concerns summary The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate these medication interaction risks.