West Yorkshire (Eastern)

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 There was no system for training or supervising parents/carers in oxygen supply transfer, nor an independent check of apparatus function and user competence before patient discharge.

Concerns summary The care facility lacked a written 'no treats policy' and a policy for ensuring a first-aid-trained staff member on every shift. Furthermore, first aid training for health support workers, especially for dependent service users, was insufficient.

Concerns summary A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.

Concerns summary Ambiguity in the surgical term "nephroureterectomy" caused critical misunderstandings between clinicians regarding procedure extent. There was also an absence of a case manager to oversee complex patient care and communication.

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 GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.

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.

Concerns summary Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.

Concerns summary Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that requires cutting back.

Concerns summary Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.

Concerns summary A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.

Concerns summary There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of all highway users.

Concerns summary Company vehicles laden with aggregates are not routinely weighed before departing the premises, posing potential safety risks on public highways.

Concerns summary The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.

Concerns summary Failures in patient transfer included no nurse escort or written handover. Prolonged A&E stay lacked clear treatment pathways and timely lumbar puncture. No falls risk assessment despite patient confusion contributed to a fall.

Concerns summary HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with severe mental health issues, a persistent concern.