Surrey

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 A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a Class A, Schedule 1 drug, despite official advice for its urgent inclusion.

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 Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. There was also staff confusion regarding responsibility for removing banned items on admission.

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 Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient public warnings regarding risks for users with cardiovascular/respiratory conditions.

Concerns summary Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, contributed to missed opportunities for timely intervention and specialist referral.

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 are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal contractors undertaking significant work-at-height projects.

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 The council demonstrated a lack of reflection and action on pothole management, with insufficient information for inspectors, mechanistic risk assessments, poor communication, and slow repairs.

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.

Concerns summary There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.

Concerns summary The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.

Concerns summary University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS liaison, and adequate systems to ensure student safety after distress.

Concerns summary An old, unserviced cot with improperly placed padded boards led to entrapment. Inadequate overnight supervision and the Children's Trust's lack of transparency, scene preservation, and proper investigation exacerbated the issues.

Concerns summary There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.

Concerns summary Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.

Concerns summary Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted as "okay," indicating a lack of clear policies and training for observation management.

Concerns summary There is a lack of clear guidance and training regarding the timely completion and accurate information gathering for the "Seven-day short stay booklet for admission/discharge."