Surrey

Concerns summary The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early death.

Concerns summary A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.

Concerns summary A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.

Concerns summary Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.

Concerns summary The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.

Concerns summary Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge and inadequate monitoring.

Concerns summary Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.

Concerns summary Insufficient dietetic staffing and inadequate staff training for complex care, including pressure sore management and patient repositioning, were concerns. There were also unaddressed issues with medication ordering and insufficient training for agency staff.

Concerns summary Deficient MOT and car service procedures fail to detect critical airbag warning light and module faults, risking deaths. Also, insufficient safety measures for young, new drivers contribute to road risks.

Concerns summary Inadequate guidance for highway inspectors on vegetation encroachment on pavements and infrequent inspections of busy footpaths pose an ongoing risk to public safety.

Concerns summary A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside a lack of risk assessment and follow-up for deteriorating mental health, created significant safety risks.

Concerns summary Hospital discharge planning policy is inadequate, with clinicians erroneously relying on patient capacity to justify unsafe discharges without proper informed consent, exacerbated by bed pressures.

Concerns summary Continuing infrastructure issues at East Surrey Hospital and a local metric for hip fracture surgery exceeding NICE guidelines delay essential operations, increasing patient risk of complications.

Concerns summary Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.

Concerns summary A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate with NHS mental health services.

Concerns summary Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult social care for care leavers. Deficiencies in risk assessment standards and non-mandatory Mental Capacity Act training persist.

Concerns summary Food labelling requirements are inadequate, failing to include warnings, guidance on dosage, and potential serious risks and side effects of excess vitamin supplements.

Concerns summary Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.

Concerns summary Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.

Concerns summary Systemic failures include a lack of demonstrated cultural change in patient care, inadequate risk assessment and management, poor information sharing, and insufficient management of intermittent observations.

Concerns summary Dementia patients at the Trust are not consistently receiving mouth care after eating, posing a risk of future deaths.

Concerns summary Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to identify and address safety issues.

Concerns summary The hospital consistently fails to meet NICE guidelines for timely hip fracture surgery for over half of patients. This non-compliance significantly increases patients' risk of early death due to delayed intervention.

Concerns summary The hospital consistently fails to meet NICE guidelines for hip fracture surgery within the recommended timeframe, delaying early mobilisation and increasing patients' risk of complications like pneumonia.

Concerns summary Hydon Hill Nursing Home failed to share critical patient information with medical staff, delayed antibiotic administration, missed a cardiac arrest, and incorrectly reported a DNAR, indicating policy and training deficiencies.