Surrey

Concerns summary Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There is also no system for effective supervisory review of initial risk assessments and safeguarding plans.

Concerns summary Ambulance service failures included incomplete 999 call triage, inconsistent major trauma protocols, delayed clinical assessment, and an inadequate system for prioritizing high-risk calls and monitoring patient deterioration.

Concerns summary Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.

Concerns summary The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person plan in place.

Concerns summary A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. Signs of sepsis were missed, and no surgical opinion was sought post-discharge.

Concerns summary Inadequate wound care knowledge, poor documentation, and ineffective specialist referral pathways in a care home setting led to difficulties in charting wound progress and providing correct care.

Concerns summary Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.

Concerns summary Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, and insufficient scrutiny of age-inappropriate online content in schools.

Concerns summary Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.

Concerns summary Insufficient senior clinical oversight at Mayday Assistance Limited and a lack of clear responsibility for patient medical management during air ambulance repatriations pose risks of future deaths.

Concerns summary The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.

Concerns summary Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating non-attendance, allowing newly referred patients to slip through the system.

Concerns summary A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.

Concerns summary A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.

Concerns summary There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals addicted to obtain large amounts despite fatal risks.

Concerns summary National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.

Concerns summary The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening door could have prevented the death.

Concerns summary Ambulance service surge management led to delayed response. Call handlers failed to ask a lone caller if he could contact someone for assistance, a script deficiency later partially addressed.

Concerns summary Unrestricted online access to detailed suicide instructions and the ability to purchase lethal quantities of substances without safeguards pose significant risks to vulnerable individuals.

Concerns summary The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.

Concerns summary Critical consultant advice on a complex medical situation was neither recorded in writing nor confirmed, risking misunderstandings between medical teams.

Concerns summary National guidance for central venous catheters in neonates lacks a key risk factor, and there's no mandatory requirement for NHS Trusts to ensure clinician familiarity or policy compliance with existing guidelines.

Concerns summary The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.

Concerns summary Failures included lack of colorectal follow-up, inaccurate malnutrition scoring, incomplete food charts, delayed recognition of weight loss, and an end-of-life decision made without full multidisciplinary team consultation.

Concerns summary A lack of adequate signage warning A322 drivers about a pedestrian crossing point creates a safety hazard for those traversing both carriageways.