Somerset

Concerns summary A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were taken to address these systemic gaps.

Concerns summary A crucial risk assessment for operating machinery near electrical equipment was absent, and this safety gap persists at other sites owned by the former estate owners.

Concerns summary Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.

Concerns summary A severe lack of safety protocols at the moto-cross track, including no rider registration, safety briefings, or skill segregation, coupled with inadequate supervision and untrained staff, highlights a critical absence of mandatory industry regulation.

Concerns summary Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.

Concerns summary Persistent non-adherence to repositioning care plans for a high-risk patient, despite repeated interventions, led to severe pressure ulcer deterioration, raising concerns about care quality and the efficacy of post-death investigations.

Concerns summary Public safety signage regarding dangerous undercurrents and rip-tides in the water is not prominent, particularly off-season, and is overshadowed by administrative signs. This leads to people underestimating significant risks.

Concerns summary There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding of their link and an absence of national guidance or training.

Concerns summary Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.

Concerns summary The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly given the potential for recipients to have mental health issues from combat service.

Concerns summary The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially to vulnerable pedestrians.

Concerns summary Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.

Concerns summary NICE guidance for head injuries is ambiguous by limiting CT scans to only anticoagulant patients, potentially overlooking other naturally occurring conditions affecting blood clotting, leading to missed diagnostic opportunities.

Concerns summary Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.

Concerns summary Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.

Concerns summary Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.