Gloucestershire

Concerns summary Concerns include insufficient ambulance resources, unclear guidance on hospital destinations for patients, and inadequate processes for expediting urgent inter-hospital transfers.

Concerns summary Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.

Concerns summary Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack of industry standards for managing spoil heaps, increasing the risk of accidents.

Concerns summary The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.

Concerns summary There are no mandatory requirements for child participants in a Hunt to wear protective equipment, demonstrate competence, or have adult supervision with a specified ratio.

Concerns summary Concerns exist regarding the appropriate escalation of care for patients experiencing acute deterioration during night shifts over weekend periods.

Concerns summary The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.

Concerns summary Concerns exist regarding care home staff's ability to identify and appropriately escalate medical concerns, including when a medical review is needed.

Concerns summary Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency information sharing and no identified lead agency for communication.

Concerns summary No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.

Concerns summary An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.

Concerns summary Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.

Concerns summary There were critical failures in escalating clinical care and a profound lack of information sharing and coordinated care among multiple departments and community services for a post-natal patient.

Concerns summary Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.

Concerns summary The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.