Hampshire, Portsmouth and Southampton

Concerns summary Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.

Concerns summary A lack of regulation, registration, and clear guidance for doulas creates confusion about their role, risks them working outside clinical boundaries, and poses challenges for midwives and patient care.

Concerns summary A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, risking delayed care and missed links to mental health decline.

Concerns summary Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to elderly and vulnerable patients needing prompt attention.

Concerns summary Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.

Concerns summary The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement in remote care.

Concerns summary A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.

Concerns summary Critical information regarding a patient's refusal of treatment may be missed due to inadequate outcome codes, leading to misleading impressions and hindering proper safeguarding and decision-making.

Concerns summary An unchecked, open trade in illegal drugs at the festival, combined with a policy that does not eject non-dealing possessors, creates a dangerous market and increases the risk of future drug-related deaths.

Concerns summary A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of an external warning label obscured safe usage requirements from users.

Concerns summary A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.

Concerns summary Inadequate gully maintenance, insufficient warning signage, and the continued presence of surface water on a known flood-risk road contributed to a fatal incident.

Concerns summary Thin surface treatments on roads can cause significantly reduced friction in early life, particularly dangerous for motorcycles in dry conditions, without adequate warning signage for drivers unaware of the altered grip.

Concerns summary The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity risk.

Concerns summary Critical failures in adhering to the hospital's post-operative care pathway for bariatric patients, including missing specialist reviews and unescalated pain, significantly contributed to the patient's death.

Concerns summary Staff in seclusion rooms could not make emergency calls directly, and paramedics faced delays accessing a patient due to unknown and unshared direct ward access routes, hindering emergency response.

Concerns summary Inconsistent regulations for high-speed RIB operations, inadequate craft design for passenger safety, poor forward visibility, and insufficient risk management systems contribute to serious impact and vibration injuries. Licensing arrangements and interim safety measures are needed.

Concerns summary Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him to misuse it for self-harm without scrutiny.

Concerns summary Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.

Concerns summary Multiple properties in the area have walls with the same unsafe dimensions as a collapsed wall, posing a risk of further collapses during severe storms and endangering lives.

Concerns summary A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication errors.

Concerns summary Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to life.

Concerns summary Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. The system failed to accelerate the process despite the evident harm.

Concerns summary A dangerous crest on a 60mph country road causes vehicles to lose control at lower speeds, exacerbated by poor visibility at night and a lack of adequate warning signs.

Concerns summary The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap in pastoral support and risk of overlooking struggling individuals.