Surrey

Concerns summary A vehicle's anti-locking braking system (ABS) critically failed after a tyre detachment, incorrectly reducing braking and creating an unaddressed design flaw. This specific scenario of tyre detachment is not accounted for in industry testing, affecting many vehicles.

Concerns summary A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to an unauthorized individual, risking future deaths.

Concerns summary A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.

Concerns summary A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.

Concerns summary There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or consideration for dilution, posing significant risk.

Concerns summary The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning Disability Liaison Nurse, leading to poor care.

Concerns summary Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A loophole also prevents unactioned court sentences from being referred back for review.

Concerns summary Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their competency.

Concerns summary Pressure ulcer risk assessments are not yet consistently embedded in the Emergency Department, and the ward continues to experience insufficient nursing staff levels for acutely ill patients.

Concerns summary Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.

Concerns summary The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import and availability of substances used for poisoning, despite known risks.

Concerns summary The care home had outdated mobility plans, lacked falls minimisation plans for at-risk residents, and failed to meet call bell response times. These systemic issues were compounded by ineffective oversight and auditing.

Concerns summary The absence of regulation on the number and weight of dogs an individual can walk in public creates significant safety risks for both dog walkers and other members of the public.

Concerns summary A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment application is delaying critical early support, increasing the risk of mental health issues and suicidality.

Concerns summary Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A new suicide risk assessment system lacks clear alerts on medical records, risking clinicians missing vital information.

Concerns summary Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent specialist oversight were significant clinical governance concerns.

Concerns summary A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general hospitals.

Concerns summary Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, information sharing between police and mental health services out-of-hours is inadequate, and risks to staff from patients' delusions were not addressed.

Concerns summary The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early death.

Concerns summary A lack of awareness regarding proper support for nursing bed mattress extensions poses a trapping risk if they detach. Furthermore, nighttime resident check procedures, though briefed, are not formalized into care home policy.

Concerns summary A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.

Concerns summary Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.

Concerns summary The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.

Concerns summary Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge and inadequate monitoring.

Concerns summary Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.