
Essex
Concerns raised19
Failure to provide clear oxygen-therapy discharge planning and referral information
Failure to review the patient before prescribing a controlled drug
Failure to consider or plan alternative pain management during opioid overdose treatment
Failure to accurately record medication administration
Non-mandatory medicines-administration refresher training for nurses
Failure to escalate medication concerns to appropriately senior clinicians
Failure to make an emergency call for an unresponsive patient
Failure of medicines-administration training to support recognition of inappropriate MST prescribing
Failure to administer MST at the prescribed frequency
Failure to provide opioid reversal in accordance with applicable guidance
Failure to administer prescribed medication
Failure to identify prescription errors and prior doses during controlled-drug checks
Failure to implement the local recommendation to include mandatory medicines-administration refresher training
Failure to scrutinise prescribed medication and medication-system information
Failure to communicate overnight deterioration and family medication concerns to the on-call doctor
Failure to provide oxygen flow meeting patient requirements at discharge
Delay and inappropriate escalation of a high NEWS score
Failure to make an emergency call after escalation of concerns
Out-of-date PAT testing for oxygen equipment
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.

Essex
Concerns raised1
Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.

Hertfordshire
Concerns raised3
Insufficient EEAS resources for demand
Delays in handover to hospital
Unsustainable public demand on the EEAS
No linked response statementsNo action or position from this recipient is clearly linked to the concerns in this report.