West Yorkshire Western

Concerns summary (AI summary) There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review to protect playing children.

Concerns On the 22/12/2016 opened an inquest into the death of Keith William Rushton who, at the date of his death was 78 years old. The inquest was resumed and concluded on 31/8/2016. Ifound that the cause...

Concerns summary (AI summary) The absence of regular checks on installed smoke and heat detectors in properties presents a safety risk, necessitating a review of maintenance arrangements.

Concerns summary (AI summary) Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.

Concerns summary (AI summary) Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.

Concerns summary (AI summary) At the inquest, it was not possible to trace an appropriate individual from the now defunct NHS direct organisation to give evidence although an internal enquiry report which had been undertaken prior to.

Concerns summary (AI summary) The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of control. Review and remedial action on these road conditions are needed.

Concerns summary (AI summary) Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns about lifeguard training and information provided to holidaymakers.

Concerns summary (AI summary) Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.

Concerns summary (AI summary) There are no life rings installed at Lock 19 on the Calder Canal, creating a clear risk of future deaths from drowning.

Concerns summary (AI summary) The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve systems for acting on discharge summaries regarding patient medication.

Concerns summary (AI summary) The need for deterrent measures on viaduct walls should be reviewed to prevent future deaths from individuals jumping.

Concerns summary (AI summary) There were significant delays in doctor review, inadequate nursing observations, and poor record-keeping by both nursing and medical staff. Crucial follow-up for medical interventions was also absent.

Concerns summary (AI summary) The trust lacked clear guidelines and up-to-date staff training for chest drain insertion, compounded by an unawareness of interventional radiologist availability, indicating systemic procedural deficiencies.

Concerns summary (AI summary) Police failed to fully report road traffic collision concerns to the council, and there are inadequate systems for risk assessment and urgent communication of needed repairs to damaged road signs and markings.

Concerns summary (AI summary) A window lacked a safety device, and remedial action is required to safeguard similar windows in properties to prevent recurrence in line with building regulations.

Concerns summary (AI summary) Inadequate discharge assessment, incomplete physiotherapy records, and unsafe patient mobilization practices, including inappropriate footwear and unsupervised transfers, contributed to a fall. The subsequent investigation was also found to be insufficient.

Concerns summary (AI summary) Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.

Concerns summary (AI summary) Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.

Concerns summary (AI summary) The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were not implemented promptly. It was also unclear whether a system was in place for reviewing risk assessments after further incidents.

Concerns summary (AI summary) The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately consider the risk of death or serious injury.

Concerns summary (AI summary) An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being unaware of a resident's prolonged disappearance until her body was discovered.

Concerns summary (AI summary) The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to perceive, which substantially contributed to the fatal accident and previous injury incidents.

Concerns summary (AI summary) The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises serious safety concerns.

Concerns summary (AI summary) Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.