Hampshire, Portsmouth and Southampton

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.

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 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 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 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 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.

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Concerns summary Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a fatal overdose.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

Concerns summary Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.

Concerns summary South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing over a footbridge parapet.

Concerns summary Carers were not required to accurately log check times, delaying understanding of events. DNACPR status was not on shift handover notes, and the emergency resuscitation pack lacked essential equipment.

Concerns summary Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.

Concerns summary The decision to change a patient's treatment location without formally consulting or adequately considering the GP's request for home treatment jeopardised continuity of care.

Concerns summary The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.

Concerns summary National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.

Concerns summary The process for renewing driving licenses for individuals over 70 lacks specific assessment of mental fitness, relying only on sight and hearing tests, despite potential cognitive impairment like dementia.