West Yorkshire (Eastern)

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 The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed to his fire-related death.

Concerns summary Hospital staff failed to recognise and escalate a patient's critical deterioration, compounded by an un-inducted agency nurse misinterpreting observations, delayed diagnostics, and overall systemic communication and competency breakdowns.

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 The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical history, omitted the risk of death, and was signed while sedated.

Concerns summary A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.

Concerns summary The primary care complaints process failed to obtain a clinical rationale from the GP practice, leading to flawed initial reviews. It's unclear how learning is shared with practices and networks.

Concerns summary The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk of trampling incidents, exacerbated by a lack of clear regulations for dogs on leads.

Concerns summary HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy directive for immediate resuscitation.

Concerns summary Significant delays occurred in making a crash call and initiating CPR for a patient who suffered cardiac arrest in A&E, due to initial misidentification of death and confusion regarding DNAR status.

Concerns summary A van's design created a large blind spot masking pedestrians, compounded by a lack of audible impact sensors and insufficient driver training and appraisal.

Concerns summary A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system places an onerous burden on drivers and limits pursuit managers' real-time oversight.

Concerns summary The nursing home lacked essential sterile catheter supplies, leading to a patient's emergency hospital admission and subsequent deterioration.

Concerns summary Network Rail failed to implement recommended mitigation measures to curtail access to railway tracks at a specific high-risk location, leaving a vulnerability unaddressed despite police warnings.

Concerns summary Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or concerns.

Concerns summary The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's specific concerns regarding systemic failures or risks.

Concerns summary Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.

Concerns summary The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.

Concerns summary An agricultural trailer lacked a required propping device and warning signs, failing to meet safety regulations. Many similar trailers remain in use without these critical safety features, posing a risk of future accidents.

Concerns summary The Philips Respironics AF 541 mask uses an insecure 'push-on' connection to the ventilator, prone to detaching, especially with a filter. A more robust docking mechanism is needed to prevent inadvertent disconnections.

Concerns summary A lethal gas risk in transformers was unrecognised due to inadequate warnings, missing manufacturer guidance on safe oil levels, and lack of recommended maintenance.

Concerns summary The hospital lacked a policy for overnight checks on vulnerable fall-risk patients, causing delayed discovery of injury. Furthermore, the bedrails policy was not adequately circulated or understood by all relevant staff.

Concerns summary Inconsistent and insufficient record-keeping, coupled with assumptions about food refusal, prevented a holistic view of the patient and delayed the recognition of deterioration.

Concerns summary Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.

Concerns summary HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.