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

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