West Sussex

Concerns summary Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.

Concerns summary Insufficient ambulance resources led to vulnerable patients being left for hours, a lack of clinical oversight in standing down ambulances, and call-takers failing to appreciate worsening conditions.

Concerns summary No specific concerns for future deaths were detailed in the provided text.

Concerns summary Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to informal versus sectioned patients, despite similar risks.

Concerns summary Severe staff shortages across paramedic and emergency operations centres resulted in delayed responses, failure to prioritize calls, and an inability to meet audit targets.

Concerns summary Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.

Concerns summary The psychiatric hospital failed to record the deceased's critical cardiac history provided by family and did not ascertain his full physical history promptly, compounded by poor information sharing between trusts.

Concerns summary There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.

Concerns summary The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and the student's GP.

Concerns summary Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation with unaware customers.

Concerns summary Inadequate lifeguard provision, including insufficient numbers, lack of medical training, and uncommunicated off-duty periods, created significant safety risks for holidaymakers.

Concerns summary Junior doctors used non-standard medical practice without consultant knowledge, and consent for women in labor was not truly informed. Crucially, these issues were not identified by the Trust's internal investigation.

Concerns summary Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back was prematurely closed and a joint investigation has not occurred.

Concerns summary Blind spot mirrors on high-fronted vehicles offer insufficient visibility for pedestrians, especially the elderly. A lack of secondary warning systems leads to over-reliance on mirrors and dangerous assumptions by pedestrians.

Concerns summary Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.

Concerns summary Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.

Concerns summary Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.

Concerns summary An ancient, high-risk rural road with poor design, unlit conditions, and a difficult, low-visibility entrance creates a dangerous situation for turning vehicles.

Concerns summary Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.

Concerns summary The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.

Concerns summary The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.

Concerns summary Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.