West Sussex

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 Lack of intervention for an immobile patient who deteriorated over two weeks at home due to refusal of medical assistance, exposing risks in community health care for vulnerable individuals.

Concerns summary Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement decisions.

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 hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for the procedure or alternative feeding methods.

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 Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.

Concerns summary Paraffin-based emollient creams lacked fire hazard warnings on labels and prescriptions, and risks were not communicated to a known smoker, highlighting a gap in NPSA guidance for lower percentage creams.

Concerns summary Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police for non-urgent welfare checks due to lack of training.

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 The railway foot crossing was poorly lit with inadequate signage, posing a danger to pedestrians who might not see or hear approaching high-speed trains, especially if distracted.

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 Poorly maintained Cardex and incident reporting systems, with unrecorded information and lack of cross-referencing, directly led to injuries not being promptly identified or followed up by staff.

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 absence of a compulsory protective helmet requirement for motorised bicycles traveling over 15 MPH significantly increases the risk of severe, unsurvivable head injuries.