Other related deaths

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 A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.

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 National training for prison staff lacks clear guidance on the safe use of force when prisoners have items in their mouths, posing a risk to breathing.

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.

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 Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.

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.