North Yorkshire and York

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 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 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 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 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.

Concerns summary An elderly patient at high risk of falls was not provided with an essential falls sensor due to equipment shortages and a long waiting list, despite the known risks.

Concerns summary Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of his critical mental state.

Concerns summary The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.

Concerns summary The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.