Surrey

Concerns summary The accumulation of wet soil and sandy deposits on the A25 Sheer Road, near a sandpit entrance, creates a road hazard for drivers.

Concerns summary Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent future deaths.

Concerns summary The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.

Concerns summary There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, leaving the patient vulnerable. This oversight was exacerbated by poor note-taking.

Concerns summary Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.

Concerns summary A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.

Concerns summary Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.

Concerns summary The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.

Concerns summary Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, compounded by unclear usage instructions.

Concerns summary The report text did not detail specific concerns, only indicating that matters giving rise to a risk of future deaths were identified.

Concerns summary The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.

Concerns summary Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.

Concerns summary A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.