Plymouth, Torbay and South Devon

Concerns summary Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.

Concerns summary A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms Unit, impacting suitability assessment for a shotgun licence renewal.

Concerns summary The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family involvement, and inadequate communication.

Concerns summary Beach signage is insufficient, lacking prominent display and specific warnings about variable riptide hazards, increasing public risk.

Concerns summary The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.

Concerns summary Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.

Concerns summary The coroner identified a critical breakdown in communication as a key concern.

Concerns summary Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of Abortion Act amendments. Foeticide should be considered before induction at this stage.

Concerns summary Critical failures in record-keeping for risk assessments and observations, inadequate staff training, and poor communication of patient status and responsibilities increased risks for patients.

Concerns summary Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices for those unable to manage risks.

Concerns summary Initial medical assessment failed to order a chest X-ray despite tender abdomen and potential cardiac symptoms, indicating an incomplete diagnostic approach for the patient's condition.

Concerns summary The provided text does not detail any specific concerns.

Concerns summary No specific concerns were detailed in the provided text, beyond broad categories of 'Nursing and Medical' matters.

Concerns summary There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.

Concerns summary An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.

Concerns summary The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.

Concerns summary The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.

Concerns summary The Pathology Department is significantly under-resourced, particularly concerning Thoracic Consultants, leading to delays and potential inaccuracies in diagnosis at this regional centre.