Isle of Wight

Concerns summary A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.

Concerns summary There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.

Concerns summary The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.

Concerns summary Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.

Concerns summary Significant breaches in Information Governance allow clinicians to alter patient records under incorrect logins, making these critical changes invisible to treating clinicians and compromising data integrity.

Concerns summary Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.

Concerns summary An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.

Concerns summary The ambulance service lacked critical understanding of Loeys-Dietz syndrome, failing to appreciate the severity of symptoms or stress the urgency of hospital transfer for a definitive diagnosis.

Concerns summary Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.

Concerns summary Poor road layout and obstructing hedgerows at a specific location compromise driver visibility, creating a significant road safety hazard.