West London

Concerns summary Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.

Concerns summary A culture of inadequate contemporaneous note-taking, especially regarding suicidal ideation, and informal, unrecorded staff communication led to critical information being lost. Junior doctors could discharge high-risk patients without senior review.

Concerns summary Pret-a-Manger had inadequate allergen labelling and no robust system to monitor allergic reactions. Additionally, Epipen's needle length and adrenaline dose were identified as dangerously insufficient for adult anaphylaxis.

Concerns summary Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.

Concerns summary A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use of early warning systems.

Concerns summary A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.

Concerns summary There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.