2016

Concerns summary Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.

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 increased speed and power of modern power boat leisure craft introduce additional risks, requiring greater awareness from users to prevent accidents.

Concerns summary A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.

Concerns summary Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.

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 Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.