2019

Concerns summary NHS Pathways for 111 call handlers failed to adequately recognize acutely unwell children due to missing questions (e.g., cold hands/feet) and inappropriately high thresholds for symptoms like green vomit.

Concerns summary Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.

Concerns summary Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.

Concerns summary A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to confusion about right of way and reduced visibility.

Concerns summary Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.

Concerns summary An electronic turning device's air mattress accidentally deflated due to a dislodged power cable, with no alarm or warning system to alert the user or staff to the critical failure.

Concerns summary A lack of appropriate training for mental health clinicians resulted in poor understanding of non-compliance risks with treatment orders and inadequate multi-agency coordination. Housing was also overlooked in discharge planning.

Concerns summary Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.

Concerns summary Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.

Concerns summary Systemic failures included significant ambulance delays, a call handler's failure to escalate a patient's worsening condition and incorrect algorithm use, and communication breakdown causing crucial treatment delays in the emergency department. A dangerous gap exists in the triage system for neurological deficits.

Concerns summary There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Concerns summary Road inspections conducted at speed failed to identify a critical drain problem, indicating an inadequate inspection process that needs urgent review.

Concerns summary Repeatedly, clinicians failed to consider a pacemaker box change as the source of undiagnosed infections, and no clear referral process existed for patients experiencing post-pacemaker surgery complications, delaying diagnosis.

Concerns summary Carers failed to properly turn off a cooker before removing knobs for a fire-risk patient, and the knob removal method itself was inadequate to ensure appliance safety.

Concerns summary A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.

Concerns summary The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.

Concerns summary The poor condition of the cycle lane forces cyclists into traffic, creating a dangerous situation and risking future lives if not repaired.

Concerns summary A stretch of road regularly experiences significant standing water and flooding, and the absence of warning signs for motorists creates a future risk of accidents.

Concerns summary The CAMHS/GP referral form is inadequate, resulting in insufficient information for risk assessment and delayed care; the Trust should reconsider redesigning the form.

Concerns summary The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.

Concerns summary Staff lacked resources to collect a patient when leave was revoked, placing an unfair burden on the family and contributing to the patient taking a fatal overdose.

Concerns summary The emergency call system lacks the capacity to link repeat calls for the same patient, preventing crucial safety-netting, senior review, and appropriate management of attendances.

Concerns summary The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.

Concerns summary There is concern that consignees, consigners, and employees lack sufficient understanding of hazards and control measures for working at height on vehicles or trailers.