East Sussex

Concerns summary An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.

Concerns summary Aortic dissection requiring emergency surgery and inter-facility transfer is insufficiently categorised, leading to delays. Reclassifying it as Category 1 is necessary to prevent future deaths.

Concerns summary The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.

Concerns summary A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process to ensure continuity of essential prescriptions when patients are removed, risking their health.

Concerns summary Basic nursing failures including inadequate oral care, mobilisation, and pressure sore management led to severe deterioration. A misleading discharge summary and insufficient root cause analysis further compounded the issues.

Concerns summary Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.

Concerns summary The transfer of critical information was inefficient, posing risks to patient care.

Concerns summary Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.

Concerns summary The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded by a lack of staff training.

Concerns summary Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.

Concerns summary Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were hidden, had insufficient rope length for low tide, and were inadequate in number.

Concerns summary Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to access NHS notes, creating information deficits that compromise risk assessments and care plans.

Concerns summary There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling incoming calls from family members concerned about a prisoner's safety, posing a risk of future self-harm or suicide.

Concerns summary Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this potential risk with patients.

Concerns summary There is a lack of understanding among care home staff and emergency call operators about circumstances where a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order should not be applied.

Concerns summary Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.

Concerns summary Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.

Concerns summary Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.

Concerns summary Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented responsibility across multiple agencies with poor communication and separate IT systems.

Concerns summary Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities to diagnose cancer and cancelling vital appointments due to resource shortages across multiple agencies with separate databases.

Concerns summary There's a systemic failure to provide integrated treatment for co-occurring serious mental illness and substance misuse, hampered by poor information sharing and an outdated Mental Health Act.

Concerns summary The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.

Concerns summary There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict beach access is needed.

Concerns summary The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.

Concerns summary Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting family contact issues.