Plymouth, Torbay and South Devon

Concerns summary Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.

Concerns summary An ambiguous hospital discharge summary on fluid intake targets caused nursing home staff to misinterpret instructions, leading to the patient's critical dehydration and contributing to his death.

Concerns summary Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.

Concerns summary Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and multi-disciplinary discussions, compromised his care.

Concerns summary There was a missed opportunity to provide timely care and treatment to the deceased before she was found in extremis.

Concerns summary Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially impacting care decisions and safety measures.

Concerns summary A dangerous road junction is prone to collisions due to drivers cutting corners, sun glare impairing visibility, and a lack of effective signage or road design to mitigate risks.

Concerns summary The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.

Concerns summary Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.

Concerns summary Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and poor record-keeping by senior staff.

Concerns summary There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.

Concerns summary No specific concerns were detailed in the provided text.

Concerns summary HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate during an emergency.

Concerns summary Concerns were raised about the proficiency of care staff in managing falls, specifically their interaction with ambulance services, accurate medical recording, and awareness of post-fall complications.

Concerns summary Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.

Concerns summary Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.

Concerns summary A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.

Concerns summary The coroner highlighted a concern regarding the implementation of recommendations from a multi-disciplinary investigation, seeking assurance they would be followed to prevent future deaths.

Concerns summary Local Authorities with high numbers of young people in care lack sufficient resources and qualified staff, further compounded by poor integration between care, mental health, and educational support services.

Concerns summary There is a nationwide lack of adequate mental health facilities and policies for complex patients with co-occurring issues and potential violence, leading to a lack of formal assessment and treatment, contravening equality legislation.

Concerns summary NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for symptoms like green vomit.

Concerns summary An independent review of UK Search and Rescue operational capability and HM Coastguard is needed, alongside a thorough review of their information technology systems for reliability.

Concerns summary Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.

Concerns summary Severe staffing shortages of radiology clinicians at Derriford Hospital are creating dangerous work pressures and increasing the risk of medical errors and fatalities.

Concerns summary A patient's disclosure of suicide risk was not properly assessed or escalated to senior staff, and relevant information was not immediately available in medical records.