Wiltshire and Swindon

Concerns summary (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI 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 (AI summary) This was at least the second fatality attributable to a Bio Ethanol burner, with previous accidental injuries also reported.

Concerns summary (AI 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 (AI summary) Concerns include inaccurate patient record keeping, delayed patient reviews despite deteriorating conditions, outdated sepsis guidelines, and insufficient training for locum and temporary staff.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 (AI 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 (AI 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 (AI 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 (AI 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 (AI summary) The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive insufficient training and follow-up.

Concerns summary (AI summary) There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding public safety.

Concerns summary (AI summary) The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns about its unregulated status and accessibility to the public.

Concerns summary (AI summary) After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to leave unnoticed, leading to his subsequent death by suicide.