Wiltshire and Swindon

Concerns summary The methadone prescribing agency was unaware of the patient's prior opioid overdose and hospital admission because discharge summaries were not shared with them. This prevented a critical review of overdose risks and potential adjustments to prescribing practices.

Concerns summary Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns between secondary and primary care.

Concerns summary The supported living accommodation's policy, which prohibits staff from removing excess medication for safeguarding without resident consent, creates a risk when residents are in mental health crisis.

Concerns summary HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide a comprehensive guide on safety obligations for charitable and voluntary organizations.

Concerns summary A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide Act and Online Safety Act, appear ineffective in preventing its marketing and supply.

Concerns summary Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of preventable deaths for patients requiring timely hospital transfer.

Concerns summary Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to an increased risk of falls.

Concerns summary Books providing explicit instructions on methods for ending one's life are freely available on Amazon.co.uk. Concerns are raised about the marketing, supply, and lack of regulation for such publications.

Concerns summary Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly patients in the hospital.

Concerns summary The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.

Concerns summary Individuals are being released from police custody far from home without adequate means for transport or communication, risking their safe return and welfare.

Concerns summary A significant delay in resuming essential anticoagulation medication, solely attributed to a weekend, raises concerns that similar delays in other cases could result in preventable deaths.

Concerns summary Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.

Concerns summary Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for appropriate care.

Concerns summary School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.

Concerns summary Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.

Concerns summary Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.

Concerns summary The provided text is incomplete and does not detail any specific concerns regarding future deaths.

Concerns summary Numerous systemic failures in mental health care include inadequate care plans, poor record-keeping, lack of family involvement, insufficient staff training and supervision, and an unsafe consultant rota.

Concerns summary Significantly worn road markings and non-functional cat's eyes on a sharp bend create a hazard, potentially causing drivers to lose positional awareness and cross onto the opposite side of the highway.

Concerns summary Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting in death.

Concerns summary Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.

Concerns summary Unrealistic expectations of junior doctors, delays in escalating care for deteriorating patients, and unclear responsibility for ensuring timely senior clinician contact were identified concerns.

Concerns summary Inconsistent and contradictory falls risk assessments, differing between hospital departments, failed to properly assess the patient's risk, leading to bed rails not being used despite immobility and involuntary movements.

Concerns summary The pedestrian crossing at the junction is unsafe due to a lack of signals, audible/vibrating assistance, and an insufficient all-red light phase, posing significant risk.