Wiltshire and Swindon

Concerns summary Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.

Concerns summary A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.

Concerns summary There have been multiple fatalities and numerous accidental injuries linked to Bio Ethanol burners, indicating an ongoing and significant product safety risk.

Concerns summary Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.

Concerns summary Staff were inadequately trained in ventilator use, unaware of the manual's location, and the provided extracts lacked crucial information for fault recognition and rectification.

Concerns summary Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.

Concerns summary No specific concerns are detailed in the provided text.

Concerns summary Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.

Concerns summary A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.

Concerns summary The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.

Concerns summary Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.

Concerns summary The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.

Concerns summary The absence of compulsory child-resistant fencing for private swimming pools in the UK, unlike other countries, creates a significant drowning risk for children.

Concerns summary A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.

Concerns summary Public parking on a Byway adjacent to a main road for Stonehenge viewing creates a significant road safety risk. Concerns were raised that diverting this byway could merely shift the problem elsewhere.

Concerns summary Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack of secure digital recording for encrypted radio signals in combat scenarios.

Concerns summary Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.

Concerns summary A child's recommended long-term therapeutic placement was delayed and ultimately overturned by Children's Services, despite multi-agency support, due to a perceived failure to meet statutory accommodation thresholds.

Concerns summary Identified road signage issues, including location and condition, were not addressed by the Highways Authority, which delayed action until a Coroner's report was issued, despite earlier recommendations.

Concerns summary The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.

Concerns summary Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.

Concerns summary Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.