Other related deaths

Concerns summary A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.

Concerns summary Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk of materials falling from vehicles.

Concerns summary A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.

Concerns summary A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to fall between existing care criteria.

Concerns summary A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.

Concerns summary The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing a risk to their safety.

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 Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.

Concerns summary National air pollution limits exceed WHO guidelines, and there is low public awareness of pollution levels. Medical professionals also fail to adequately communicate the adverse health effects of air pollution.

Concerns summary A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in use after an inspection.

Concerns summary A lack of national guidance on suspending domiciliary care packages and coordinating information sharing for vulnerable patients discharged from urgent care poses a risk to continuity of care.

Concerns summary The care provider demonstrated a lack of transparency, failed to update and communicate care plans effectively, and over-relied on an insecure WhatsApp group for critical service user information.

Concerns summary Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading to misinterpretation of needs.

Concerns summary Pedestrian safety on the A2100, Battle Hill, needs review following a fatal road traffic collision, highlighting concerns about highway safety for those crossing the road.

Concerns summary England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.

Concerns summary The road junction has a history of serious collisions due to poor visibility, deceptive road layout, and inadequate signage/safety measures, despite being a high-traffic route.

Concerns summary There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.

Concerns summary The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening door could have prevented the death.

Concerns summary DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors or flexible appointment management.

Concerns summary The ambulance call handler script failed to provide realistic arrival times or suggest alternative transport, hindering informed decisions. It also lacked emphasis on attending acute hospitals or re-calling upon patient deterioration.

Concerns summary The "Alternative to Transfer" service for care homes, designed to reduce ambulance calls, introduces an additional triage layer that may delay admissions, yet lacks proper audit for adverse outcomes or deaths.

Concerns summary The company failed to demonstrate occupational health checks or compliance with HSE guidelines for employees exposed to respirable crystalline silica, potentially increasing their risk of developing severe diseases.

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 Smart motorways present foreseeable risks due to the absence of a hard shoulder and the inability to quickly identify stationary vehicles, necessitating better driver awareness and a wider public inquiry beyond inquest limitations.

Concerns summary Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.