West Yorkshire (Eastern)

Concerns summary The hyper-acute stroke unit offers a thrombectomy service for only 20.8% of the week, denying patients crucial time-sensitive treatment based on their home address and time of stroke.

Concerns summary Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.

Concerns summary A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.

Concerns summary Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and posing a foreseeable risk of drawing individuals into self-harm.

Concerns summary The Trust failed to maintain nurse training records, preventing assurance of competence, and neglected to create a formal care plan for a critically ill child, leading to disputed treatment.

Concerns summary The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.

Concerns summary Disjointed management and lack of identified consultants for a high-risk pregnancy led to poor continuity of care. Critical information about fetal inactivity went unreported and unheeded, causing a delay in necessary intervention.

Concerns summary The absence of a defibrillator at Marshalls Arts College poses a critical safety concern.

Concerns summary The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.

Concerns summary Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.

Concerns summary Operatives work in dangerously restricted spaces near rotating industrial saws, and machines continue to pass with insufficient clearance, posing a significant risk of fatal injuries due to unaddressed safety measures.

Concerns summary The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.

Concerns summary A diseased tree, despite prior examination, had a hidden severe fungal decay that was missed due to inadequate inspection and misidentification of the condition, leading to an underestimation of its felling urgency.

Concerns summary Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.

Concerns summary Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.

Concerns summary No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.

Concerns summary A busy road frequently used by pedestrians, including children, lacks a pedestrian crossing, posing a significant safety risk.

Concerns summary A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite its location next to a main road.

Concerns summary Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.

Concerns summary No specific safety concerns were detailed in the provided text.

Concerns summary A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.

Concerns summary Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.

Concerns summary Hospitals lacked routine chemical thrombo prophylaxis and formal risk assessment for venous thromboembolism in low-risk patients with conservatively treated lower limb injuries.

Concerns summary The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.

Concerns summary Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.