Hampshire, Portsmouth and Southampton

Concerns summary The 999 call system caused confusion and delays in emergency response for a mental health crisis at home due to unclear agency responsibilities and lack of public awareness.

Concerns summary Critical issues include a lack of continuity in antenatal care, insufficient safe-sleeping advice provided post-natally, and midwives' unawareness of criminal implications of infant overlay with alcohol/drugs.

Concerns summary The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.

Concerns summary Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a fatal overdose.

Concerns summary Specific concerns were unavailable as the text referenced an attached sheet.

Concerns summary Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.

Concerns summary Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.

Concerns summary Citywatch radio reports of serious disturbances are not being relayed to police in a timely manner, risking delayed emergency response and a lack of clear protocols for licensed security staff.

Concerns summary Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood their powers to detain informal patients. Confusion also existed regarding family involvement in care planning.

Concerns summary There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.

Concerns summary There are no formal, effective national procedures for halting cycle races after an accident, leading to other riders passing through dangerous aftermaths.

Concerns summary Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from unprogressed requests and incorrect referral classifications.

Concerns summary Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication protocols between staff and ambulance services were inconsistent.

Concerns summary Inadequate staffing and training for NICU staff, particularly in escalating concerns and recognizing respiratory distress, compounded by unclear roles, poor observation recording, and deficient handover systems.

Concerns summary Lack of first aid training for staff moving residents after falls poses a risk of exacerbating injuries, as the city council discontinued this essential training.

Concerns summary A narrow, pinch-point corner on a shared cycle/pedestrian pavement posed a safety risk due to poor visibility and the absence of a safety barrier.

Concerns summary Other local authority Adult Services could benefit from lessons learned and actions taken in this case to address shortcomings, suggesting the need to share this information widely.

Concerns summary Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.

Concerns summary Hospital staff delayed police notification of a suspicious death due to procedural confusion. Additionally, ambulance handover and private ambulance communication lacked critical patient location details, hindering investigation.

Concerns summary The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.

Concerns summary Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.

Concerns summary There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.

Concerns summary There is no confirmation that recommended safety upgrades, such as installing door limit switches on goods lifts, have been implemented, posing a continued risk on this and potentially other ships.

Concerns summary The unmanned and unprotected railway crossing relies solely on a distant train horn for warning, with previously obscured visibility contributing to safety risks.