Surrey

Concerns summary Contradictory information in discharge summaries led to the discontinuation of life-saving medication, which clinicians failed to identify despite patient contact. Additionally, occupational therapy recommendations for support were not ensured post-discharge.

Concerns summary The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.

Concerns summary The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.

Concerns summary Insufficient consideration of increasing cyclist numbers on highways leads to inadequate defect categorisation, prioritising cycle lanes over highways where many cyclists also face significant risks.

Concerns summary The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no action plan for patient intolerance or airway emergencies.

Concerns summary Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.

Concerns summary An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate imaging or confirmation of its position, delaying critical haemothorax management.

Concerns summary The lack of a safe or controlled pedestrian crossing on the main A25 road in Abinger Hammer village poses a significant risk to locals and visitors, especially families.

Concerns summary Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.

Concerns summary A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.

Concerns summary Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.

Concerns summary Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.

Concerns summary Inadequate review of patient history and imaging before invasive procedures, insufficient respiratory consultant input, and poor communication between medical teams increased risks. Staff also lacked training to access historical imaging.

Concerns summary The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.

Concerns summary Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.

Concerns summary Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.

Concerns summary Inadequate training and communication between police and hospital staff on missing persons procedures led to critical information omissions, misclassification, and a complete failure to investigate Mr. Hafele's whereabouts.

Concerns summary Oxygen flow was lost due to an improperly engaged humidifier screw cap, exacerbated by the absence of an alarm on the concentrator and insufficient training regarding equipment setup.

Concerns summary Discharge follow-up mechanisms were inadequate for patients transferring areas, leading to a lack of continuity of support, and follow-up letters for non-contact were inappropriate.

Concerns summary Poor GP documentation, lack of routine monitoring, and a presumption of psychological problems without excluding organic causes led to delayed diagnosis of an underlying physical condition. Systemic failures in electrolyte management and inter-service communication were also identified.

Concerns summary Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.

Concerns summary Significant delays in clot treatment and CTPA scans were caused by poor communication during handovers and between medical staff. Additionally, medical notes had gaps and vulnerable patients had unsupervised access to stairs.