West Sussex

Concerns summary Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.

Concerns summary The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.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 Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential diagnostic tests like ECGs. Poor communication during staff handovers and with families also compromised care.

Concerns summary Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.

Concerns summary Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.

Concerns summary There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.

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.

Concerns summary Inadequate discharge planning from a mental health hospital, including poor communication and unsuitable accommodation, left a vulnerable patient without proper support.