Surrey

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 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 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 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.

Concerns summary There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking fatal misplacement.

Concerns summary The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.

Concerns summary The ambulance service (SECAMBS) is consistently operating at a critical surge level, where demand significantly exceeds resources, leading to a failure to meet target response times and risking future deaths.

Concerns summary The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and difficulty in accurately auditing prescribing history, posing a risk of medication errors.

Concerns summary A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient safety through delayed response times.

Concerns summary The deceased had a long history of complex mental health conditions, including Autistic Spectrum Disorder, indicating challenges in managing his specific needs.

Concerns summary An ongoing risk of further aquaplaning deaths exists on the M25 due to a persistent road "flat spot" and surface water issues, despite a history of incidents and previous PFD reports, as a comprehensive risk management plan remains unfulfilled.

Concerns summary There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.

Concerns summary Lethal substances are readily available for purchase online and delivered within the UK without safeguards to protect vulnerable individuals from making such purchases.

Concerns summary Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to vulnerable patients.

Concerns summary A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and crucial information not being disclosed.