Hampshire, Portsmouth and Southampton

Concerns summary Hospital staff failed to conduct a mental health assessment for a patient with obvious self-harm and suicidal ideation, contradicting NICE guidelines. Critical suicidal ideation was also not adequately recorded.

Concerns summary Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital annual blood tests due to inconvenient separate phlebotomy appointments.

Concerns summary Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety protocols.

Concerns summary Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic systems, and some records remain paper-based.

Concerns summary Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains ineffective, and the Personality Disorder Pathway development is too slow.

Concerns summary Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the property. The source of the carbon monoxide toxicity remains unascertained.

Concerns summary Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.

Concerns summary Nursing care plans and risk assessments were not adequately updated, and there was poor adherence to the hospital's hydration policy, leading to patient dehydration without clear accountability.

Concerns summary Carers regularly left medication unsecured, despite an identified risk of misuse. The digital care plan also failed to instruct carers to secure the medication, posing a safety risk.

Concerns summary A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting MAPPA professionals, posing a risk of future deaths.

Concerns summary Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.

Concerns summary A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative measures.

Concerns summary Emergency department and trauma staff lacked widespread awareness of checking the back of the throat in patients with epistaxis or facial fractures, potentially missing continued bleeding.

Concerns summary The caregiver failed to identify unconsciousness and delayed summoning medical assistance, demonstrating a critical lack of training and skills in recognizing and responding to medical emergencies.

Concerns summary Critical patient allergy information was not accessible or flagged to clinicians, despite being recorded in medical notes, resulting in the inappropriate prescription of a contraindicated medication.

Concerns summary A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment method was insecure, posing risks for similar helmet-mounted accessories.

Concerns summary Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.

Concerns summary A lack of visible and prominent signage regarding the live electrified third rail at the railway station meant individuals were unaware of its presence and life-threatening danger.

Concerns summary The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform the DVLA.

Concerns summary Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory factor to depression in peri-menopausal women.

Concerns summary Care home's "Post-Falls" policy lacked clarity on when to call emergency services for possible head injuries, and staff training on recognising intracranial injury was insufficient.

Concerns summary The Trust's head injury policy was outdated, failing to reflect revised NICE guidance requiring a CT scan within 8 hours for patients on any anticoagulant, leading to delayed diagnosis.

Concerns summary Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.

Concerns summary The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.

Concerns summary A busy main road lacks safe pedestrian and cycle crossings, forcing individuals to navigate dangerous sections where pathways end, significantly increasing the risk of serious collisions.