Gloucestershire

Concerns summary A patient was removed from a soft food diet without proper assessment or documentation, and external food was not checked for suitability by care home staff, risking future deaths.

Concerns summary Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient care.

Concerns summary There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.

Concerns summary GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.

Concerns summary There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.

Concerns summary Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, poor handovers, insufficient personnel change notifications, and a lack of mandatory training or oversight.

Concerns summary Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.

Concerns summary Significant radiology department understaffing, national trainee shortages, and delayed hiring of call handlers collectively strain resources, leading to concerns about timely reporting of scans.

Concerns summary There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures at diving centres.

Concerns summary Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.

Concerns summary Signallers lacked instructions for extracting information from users, and authorities had not sufficiently considered closing the railway crossing.

Concerns summary The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.

Concerns summary A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.

Concerns summary There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working at height on vehicles or trailers.

Concerns summary The lack of a mandatory requirement for electrical inspections in private rental properties, adhering to BS7671 standards, poses a risk of future deaths.

Concerns summary Concerns include insufficient falls prevention measures, inadequate understanding of post-fall protocols and medication review, and poor handover of patient safety information between wards.

Concerns summary The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.

Concerns summary The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for patients.

Concerns summary Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.

Concerns summary A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.

Concerns summary Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.

Concerns summary A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency assessment referral was made.

Concerns summary The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.

Concerns summary A patient with cross-border care arrangements was unable to access therapeutic services because her healthcare was commissioned by one county and social care by another.