West Sussex

Concerns summary Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.

Concerns summary There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to medication adherence.

Concerns summary A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, creating a serious risk of vulnerable patients absconding.

Concerns summary Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, missing opportunities for earlier specialist assessment.

Concerns summary There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history in acute and mental health settings.

Concerns summary There's a critical lack of compulsory fire safety provisions, such as sprinklers, in extra care facilities for vulnerable, immobile residents, leaving them at significant risk of death from fires.

Concerns summary The absence of mandatory medical checks for drivers over 70, relying instead on self-declaration, poses a serious risk to road users as enduring medical conditions may go undetected, contributing to fatal accidents.

Concerns summary Failures included not excluding tension pneumothoraces during cardiac arrest, delayed recognition of surgical emphysema, and the anaesthetic department's failure to investigate or conduct a robust morbidity review after the patient's death.

Concerns summary Inadequate JRCALC guidance on footling breech presentation led to an inappropriate home delivery attempt and delayed hospital transfer. There is also a critical shortage of consultant midwives providing obstetric support across ambulance services.

Concerns summary Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable older adolescents, missing crucial support opportunities.

Concerns summary Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs lacking clear guidance on escalating concerns.

Concerns summary Delivery van drivers, exempt from Working Time Regulations, can work excessively long hours without mandatory breaks, posing a significant risk to public safety, particularly pedestrians in populated areas.

Concerns summary Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.

Concerns summary There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.

Concerns summary Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.

Concerns summary The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to discern turning intentions.

Concerns summary Govia Thameslink Railway lacked mandatory staff training for vulnerable persons, used inappropriate protocols for welfare concerns, and failed to adequately log actions or share critical information with other agencies.

Concerns summary Current regulations for Crash Resistant Fuel Systems (CRFS) in rotorcraft are inadequate, failing to mandate retrofits or provide a public register. This leaves a high risk of post-crash fires and prevents informed public decision-making.

Concerns summary The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call handlers and an inadequate system for disabilities. The public is also misled about the service's diagnostic capabilities.

Concerns summary Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.

Concerns summary Insufficient awareness among patients, families, and carers about the increased fire risk from flammable emollient creams, especially when combined with air mattresses, poses a significant safety concern.

Concerns summary Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.

Concerns summary A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, and suffering from poor sight lines.

Concerns summary A national shortage of inpatient beds at specialist eating disorder units meant a patient could not receive urgent treatment, highlighting a systemic risk of serious harm and death to vulnerable individuals.

Concerns summary A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.