West Sussex

Concerns summary A critical lack of information sharing and communication across agencies, compounded by emergency department triage delays, prevented accurate risk assessment and timely action for a vulnerable patient.

Concerns summary The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.

Concerns summary Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service gaps for high-risk individuals.

Concerns summary Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and exacerbated mental health conditions.

Concerns summary NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.

Concerns summary There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack sufficient understanding of available housing options and appropriate release planning.

Concerns summary The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.

Concerns summary Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and joint working protocols between police and mental health services.

Concerns summary Neonatology Consultants are not immediately on-site overnight or weekends at two distant hospitals, and variable response times due to travel constraints pose a risk in emergencies.

Concerns summary A critical Mental Health Treatment Requirement was not transferred or communicated between Trusts, highlighting a systemic failure in MHTR administration and probation oversight.

Concerns summary Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term steroid use, pose a fatal risk despite local improvements.

Concerns summary Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for mental health assessments of intoxicated individuals, compromised appropriate care in custody.

Concerns summary Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an inappropriate surgical technique.

Concerns summary Care home staff failed to consider choking despite the resident having recently eaten, and consequently did not attempt life-saving techniques.

Concerns summary The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing patient records, risking missed reviews and unintended cessation of vital medications.

Concerns summary Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the baby.

Concerns summary A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support and patients falling through service gaps.

Concerns summary Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, as a failure to refer for cancellation contributed to despair and death.

Concerns summary Crucial medical notes for the deceased baby were largely completed retrospectively by a midwife not directly involved in her care, with limited contemporary documentation. This resulted in inaccurate information for treating clinicians.

Concerns summary Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a missed opportunity to administer a potentially life-saving antidote.

Concerns summary A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical failure in medical management.

Concerns summary A nationwide shortage of care providers and carers prevents commissioned care packages from being fulfilled, risking individuals not receiving necessary care with potentially fatal results.

Concerns summary Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.

Concerns summary Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.

Concerns summary The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.