Oxfordshire

Concerns summary Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.

Concerns summary Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.

Concerns summary Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.

Concerns summary Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.