West Yorkshire (Eastern)

Concerns summary Critical failures in discharging a vulnerable person home included no falls alarm, no working phone, no risk assessment for emergency contact, unchecked utilities, and inadequate social worker training on home suitability checks.

Concerns summary An unmanned, remote site known for youth trespass has deep, uncovered water channels and inadequate perimeter security, presenting a foreseeable drowning risk that remains unaddressed.

Concerns summary The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously ill prisoner to hospital.

Concerns summary Hotels lack readily accessible and accurate guest/staff lists for emergency services, leading to critical delays in rescue efforts due to time lost establishing who was missing.

Concerns summary Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and abnormal vital signs. Unclear escalation procedures and inadequate staff training risk similar future incidents.

Concerns summary The landlord rented out a non-compliant cellar flat, raising concerns about similar hazards, including inadequate smoke detection and escape routes, in other properties. There is no ongoing duty for landlords to check smoke alarm effectiveness.

Concerns summary Admitting unsupervised 16-17 year olds to festivals where illicit drugs and alcohol are prevalent exposes vulnerable teenagers to significant harm, raising concerns about licensing bodies' responsibility.

Concerns summary Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for emergency medical assistance.

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 Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and patients. Nursing agencies failed to share health vulnerabilities.

Concerns summary Inadequate risk assessment procedures led to untrained staff performing hazardous tasks. The safety boat's permissioning system was ineffective, allowing unauthorised operation, and the weir lacked a safe platform for debris removal.

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 Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.

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 A lack of regulatory oversight for BBL procedures in the UK, coupled with insufficient and untimely provision of information for informed consent, exposes patients to significant mortality and morbidity risks.

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 HGV lacked warning devices, its driver was untrained to report hazards, and ineffective rear hazard lights made the stranded vehicle dangerously inconspicuous, increasing collision risk.

Concerns summary The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.

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

Concerns summary The absence of facilitated pedestrian crossing points and sparse crossing infrastructure in a busy area, combined with poor street lighting, creates a significant hazard for pedestrians.

Concerns summary Concerns related to the process of identifying and responding to a patient's deteriorating lung condition, noted through serial CT scans and MDT reviews.

Concerns summary A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best interests' meeting or family involvement, highlighting a systemic problem with hasty discharges.

Concerns summary A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.

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 nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.