Plymouth, Torbay and South Devon

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 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 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 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.

Concerns summary "Self-certification" for medication without GP notification allows vulnerable patients with addiction issues to obtain potentially toxic drugs like Amitriptyline unchecked, removing a crucial safeguard.

Concerns summary The radiology department lacked sufficient CT resources and staff for simultaneous emergencies, causing reporting delays, and had no internal major incident policy to guide responses.

Concerns summary It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.

Concerns summary A partially blocked road drain caused water to cascade across the carriageway, and inadequate safety barriers failed to prevent a vehicle from leaving the road where the ground dropped steeply.

Concerns summary Poor communication with the family and a shortage of care coordinators meant the patient lacked advocacy, and his family was unprepared for deterioration after psychiatric discharge.

Concerns summary The crisis team failed to advise that presenting at the emergency department was an option for urgent mental health assessment, and the patient's friend was unaware of this critical pathway.

Concerns summary The absence of "no through road" signs at the start and reflective warnings at the dead-end wall risks drivers reaching a sudden, unexpected obstruction.

Concerns summary Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check on the deceased's wellbeing.

Concerns summary The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.

Concerns summary Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.

Concerns summary Emergency call handling protocols inadequately categorised severe symptoms like "dizziness" for rapid response, compounded by a lack of clinical training and insufficient supervisor oversight for call handlers.

Concerns summary Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.

Concerns summary Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance and a failure to routinely use inclinometers, despite known risks from slight gradients.

Concerns summary Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.

Concerns summary A shortage of Cardiac Intensive Unit Specialist Nurses puts post-operative patients at risk.

Concerns summary Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family information on admission.