City of Kingston Upon Hull and the County of the East Riding of Yorkshire

Concerns summary Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also an over-reliance on private care with insufficient oversight.

Concerns summary Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. Additionally, electronic patient records failed to track author changes on discharge letters, risking miscommunication.

Concerns summary Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and ensuring safe ongoing care.

Concerns summary The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading to the irretrievable loss of critical, time-sensitive evidence.

Concerns summary An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, even if a post-mortem isn't needed, impeding scientific progress.

Concerns summary Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and interaction. Delays in emergency service response further leave staff unequipped to handle vulnerable people for extended periods.

Concerns summary A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.

Concerns summary Inconsistent staffing within Home Based Treatment Teams hinders patient engagement and honesty during fragile periods. Addressing this requires additional funding, recruitment, and retention to ensure continuity of care.

Concerns summary There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if abandoned, to manage obstetric problems.

Concerns summary A pharmacy delivery agent, lacking training and dementia awareness, moved an elderly patient who had fallen and resisted help. There's a critical lack of clarity regarding staff responsibilities in such situations.

Concerns summary Repeat fatal incidents on a specific road bend highlight concerns about inadequate safety measures and a lack of clear timescales for assessing and implementing additional road markings despite discussions between authorities.

Concerns summary The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous taxi operations, and insufficient traffic management for intoxicated crowds.

Concerns summary Motorcyclist helmets are detaching in collisions, but there's a lack of research into why, no checks for correct helmet sizing, and inadequate rider education on proper fit, increasing fatality risks.

Concerns summary There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled with inadequate awareness and training for medical staff on essential holding powers.

Concerns summary Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a lack of understanding of resident needs and falls policies.

Concerns summary Systemic failures included a lack of recognition for the link between domestic abuse and suicide, inadequate identification of vulnerable individuals, and poor inter-agency information sharing. There was no single point of contact for complex cases and insufficient police training on domestic abuse and suicide risk.

Concerns summary The 111 algorithm failed to prompt urgent paediatric referral for a critically ill child, inadequately considering parental concern, prior GP review, and timing of advice, leading to delayed optimal care.

Concerns summary Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation and storage, despite their lethal capabilities, poses a significant public safety risk.

Concerns summary There was an absence of window restrictors on multiple windows within the building, posing an ongoing fall risk for residents, despite one having been replaced post-incident.

Concerns summary Westfield Lane is a dangerous accident blackspot with a history of multiple fatalities and accidents, highlighting an urgent need for highway safety improvements.

Concerns summary The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped with such apparatus to improve survival rates in cardiac arrest.

Concerns summary The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.

Concerns summary The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.

Concerns summary The widespread availability of alcohol-based hand washing gels poses a risk of consumption by confused patients, and there's inadequate dissemination of this hazard and the need for formal risk assessments across sectors.

Concerns summary The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.