Plymouth, Torbay and South Devon

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 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 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 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 Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient staff understanding of "Nil by Mouth" for complex patients.

Concerns summary GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from services.

Concerns summary The over-70 driving license renewal system relies on self-reporting and lacks mandatory objective testing, failing to prevent individuals with unrecognised cognitive impairment from driving.

Concerns summary There are conflicting expert opinions regarding a potentially defective cardiac valve, with the operating surgeon identifying a defect not confirmed by an independent review.

Concerns summary The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.

Concerns summary Concerns included unsuitable living accommodation, evident self-neglect, and an inappropriate care package for the deceased, indicating systemic failures in supporting his welfare.

Concerns summary Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.

Concerns summary The provided text was incomplete and did not specify the coroner's concerns regarding safety issues or systemic failures.

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