Surrey

Concerns summary A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque specifications from suppliers creates an ongoing safety risk.

Concerns summary Community alarm installation officers may not have thoroughly range-tested devices, risking alarms not functioning throughout clients' homes, affecting a significant number of existing users.

Concerns summary Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.

Concerns summary The parameters for Supplementary Restraint System (airbag) deployment may be inadequate, failing to activate airbags in collisions where impact is absorbed by the crumple zone away from sensors, resulting in severe injury or death.

Concerns summary Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.

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 There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing delivery services about potential dangers, and no policy preventing drivers from entering without prior contact.

Concerns summary Nursing staff lacked sufficient knowledge of the choking policy and understanding of when to provide life-sustaining treatment in the presence of a DNAR order.

Concerns summary Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval prolongation.

Concerns summary Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.

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 Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the risk of harm.

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 Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National guidelines on bariatric surgery in pregnancy are also lacking.

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 Inadequate awareness programmes exist for the importance of fitting and maintaining smoke detectors in mobile and static caravans, increasing fire safety risks.

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 Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.

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 Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.

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.