North Yorkshire and York

Concerns summary Inconsistent provision of mobility aids during patient transfers between hospital wards, as walking frames do not automatically follow patients, posing a fall risk.

Concerns summary Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic record accessibility.

Concerns summary Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and learn lessons.

Concerns summary Persistent failures in patient identification processes, including staff not checking identity and delayed recognition of errors, continue to pose a significant risk to patient safety across hospital sites.

Concerns summary Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.

Concerns summary The hospital failed to prioritise a seriously ill patient, overlooking critical medical alerts and existing diagnoses, and neglected to consult specialists, leading to significant delays and inappropriate treatment.

Concerns summary Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.

Concerns summary An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic failures in patient assessment and incident learning.

Concerns summary The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.

Concerns summary A significant delay in investigating a missed abdominal pathology on a CT scan, which contributed to the patient's death, resulted in no proper harm assessment and a failure to disclose the error to the family.

Concerns summary The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.

Concerns summary The absence of a legal requirement for seatbelts in the rear of motorhomes for adults and children over three creates a significant public safety risk.

Concerns summary Poor discharge procedures, unrecorded post-discharge infection concerns by nursing staff, and critical inter-hospital communication failures led to missed opportunities for timely patient assessment and treatment.

Concerns summary The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and lacking residential substance misuse treatment facilities for minors.

Concerns summary A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about the adequacy of current regulations and strength assessments for harness fitting points in cars.

Concerns summary The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns about inadequate pre-treatment assessment and the need for mandatory First Aid training for chiropractors.

Concerns summary Non-police prosecuting authorities, such as HMRC, lack automatic checks to flag individuals holding firearms licenses, preventing assessment of their suitability to possess weapons when facing prosecution.

Concerns summary Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, including the higher suicide prevalence for autistic individuals. Staff lacked understanding of specialist team access.

Concerns summary Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.

Concerns summary A specific road section is dangerously prone to severe surface water accumulation due to inadequate drainage and poor design, creating a high risk of accidents exacerbated by a lack of warning signs. Permanent engineering changes are critically needed.

Concerns summary The provided text indicates general concerns exist that risk future deaths, but does not detail the specific issues or systemic failures identified by the coroner.

Concerns summary A critical lack of accessible water rescue aids, including flotation devices or throw lines, at the incident scene hindered efforts to save a non-swimmer.

Concerns summary The absence of street lighting in a dark area with bus stops near a popular venue creates a significant road safety risk for pedestrians.

Concerns summary Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.