Other related deaths

Concerns summary A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for hours after a fall.

Concerns summary An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.

Concerns summary Council records are potentially contaminated with asbestos fibres, posing a risk of exposure and fatal mesothelioma to anyone handling them.

Concerns summary Many recommendations from the 2014 National Review of Asthma Deaths remain unimplemented. Conflicting guidelines and insufficient training for clinicians further compromise safe asthma care.

Concerns summary NHS 111's assessment pathway failed to account for a patient's significant medical history, leading to an incorrect referral. The call was then closed due to an incorrect number, missing a crucial opportunity for care.

Concerns summary Virtual consultations risk misunderstanding due to lack of written follow-up. Inconsistent initial questioning across emergency services leads to incomplete clinical triage, and paramedic patient leaflet information is often inaccurate.

Concerns summary Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.

Concerns summary Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.

Concerns summary Certain vehicle configurations, with low-height, protruding mirrors and guards, create a risk of serious injury or death to people overtaken by these vehicles.

Concerns summary The Busway has significant design flaws with numerous accessible pedestrian entry points, insufficient warning signage, and a lack of physical barriers, leading to repeated severe incidents.

Concerns summary Critical fire safety standards (Code of Practice and British Standard 5839 LD1 Maximum Protection) are not statutory requirements, which may compromise safety.

Concerns summary A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.

Concerns summary Conventional smoke alarms may be ineffective for children under 16, particularly boys, suggesting mandatory fire suppression systems in all new properties, similar to Wales, should be considered.

Concerns summary Communication between Staffordshire Fire and Rescue Service and domiciliary care providers needs improvement to ensure awareness when clients are not using provided fire safety equipment.

Concerns summary Consideration should be given to fire and smoke alarms specifically designed for people with dementia, which could improve safety for this vulnerable group.

Concerns summary There was no local protocol for managing anticoagulated patients over 65 who suffer head trauma, especially when also receiving treatment-dose Clexane.

Concerns summary Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.

Concerns summary Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.

Concerns summary Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.

Concerns summary The care home failed to prevent residents with learning disabilities from accessing hazardous items, didn't escalate previous incidents, and lacked adequate night staff monitoring for wandering residents.

Concerns summary An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction entries in medical records.

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 There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.

Concerns summary Despite guidance, young parents are continuing unsafe co-sleeping practices, often involving alcohol or drugs, and are not appreciating or following advice on safe sleeping environments, risking infant deaths.

Concerns summary Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.