Other related deaths

Concerns summary District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when a patient's life was at risk.

Concerns summary An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river below.

Concerns summary Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack of multi-agency risk assessment. There were also significant communication breakdowns between mental health services and the police.

Concerns summary Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk of falls and potential death.

Concerns summary A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.

Concerns summary A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a future fall risk.

Concerns summary A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide their location to emergency services.

Concerns summary The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.

Concerns summary Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant issues to police.

Concerns summary Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.

Concerns summary A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.

Concerns summary Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.

Concerns summary Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.

Concerns summary Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.

Concerns summary National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.

Concerns summary Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.

Concerns summary Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of detection technology.

Concerns summary Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.

Concerns summary Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.

Concerns summary Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.

Concerns summary The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.

Concerns summary The hospital failed to involve the patient's primary carer in discharge planning and neglected to provide holistic information about his fluctuating delirium, including potential aggression, leaving carers unprepared for his complex needs.

Concerns summary The steps are unsafe as the handrail is too low and short, preventing individuals from adequately steadying themselves when descending.

Concerns summary Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.

Concerns summary The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.