Other related deaths

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 A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.

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 The absence of safety signage on a public footpath near a severe drop at a reasonably frequented viewing spot poses an avoidable risk of fatal falls.

Concerns summary Inadequate legislation and a lack of internet sales prohibitions allow dangerous DNP 'diet pills' to remain readily available online, leading to numerous deaths among vulnerable people.

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 Online platforms actively promoted suicide methods and dangerous substances to vulnerable young men, undermining mental health support and posing a foreseeable risk of drawing individuals into self-harm.

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 A hazardous gap and sloped surface by a footbridge in a public park pose a danger to users, especially at night, with unclear responsibility between local authorities.

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.

Concerns summary Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication with care providers. Patient monitoring was also insufficient, and CPR wasn't initiated when warranted.

Concerns summary Reduced lifeguard cover on Cornish beaches lacks a clear, publicly available plan detailing coverage levels or how shortfalls will be mitigated by other emergency services, increasing safety risks for bathers.

Concerns summary Concerns persist regarding reduced coastguard and lifeguard cover on the Cornish coastline, with no transparent, published plan on mitigation strategies or current service levels available to the public.

Concerns summary The drug information leaflet for doxycycline failed to highlight the possibility of a psychotic reaction, which the deceased experienced, hindering early intervention by her family.

Concerns summary The ambulance service's automatic Category 4 response for residential facility calls lacking patient contact, combined with poor update clarity, means evolving critical situations are not adequately reassessed.

Concerns summary Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between medication charts and actual stock.

Concerns summary The department's refusal to investigate or acknowledge its mistakes prevents essential learning, creating a significant risk of future preventable deaths.

Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.

Concerns summary The complete absence of professional lifeguard cover on Cornish beaches poses a significant risk of further loss of life. A lack of transparent planning for resuming this essential service leaves the public vulnerable.