Other related deaths

Concerns summary Organisational failures, including the use of inappropriate wood in equipment and a lack of accountability for annual inspections due to unclear role demarcation, led to a fatal incident.

Concerns summary Pilot licensing does not mandate instruction and testing in partial engine power loss scenarios for light aircraft, despite this being a common and challenging factor in crashes.

Concerns summary Unsafe access methods to the cellar and insufficient guarding of cellar steps against accidental public entry pose a safety risk.

Concerns summary Lack of barrier maintenance, absent permanent barriers, inadequate international warning signs, and insufficient staff training at cliff hot spots create significant safety hazards.

Concerns summary Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing essential contact.

Concerns summary The company lacked documented rationale for employee suspension, failed to consider risk factors or offer support services, and kept inadequate meeting records, raising concerns about employee welfare.

Concerns summary The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on licence and had a procedural failure in referring licence breaches back to the Parole Board.

Concerns summary A community alarm operator ended a call with an elderly man who had fallen before he could get up, without checking for emergency contacts. This raises concerns about fall response protocols and subsequent safety.

Concerns summary A lack of appropriate warning signage about water risks, especially with inflatables, and no lifeguard supervision contributed to the death in Roker Harbour.

Concerns summary Inadequate and undocumented disclosure of a child's background information to prospective foster carers caused anxiety and posed a risk to informed placement decisions.

Concerns summary Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.

Concerns summary The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.

Concerns summary There are no Automated Electronic Defibrillators (AEDs) available on trams or at tram stops across the Metrolink network.

Concerns summary Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements and missed public protection opportunities.

Concerns summary Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.

Concerns summary The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet use, creating an unsafe environment.

Concerns summary There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing delivery services about potential dangers, and no policy preventing drivers from entering without prior contact.

Concerns summary The installed stair lift does not stop in a safe position at the top, leaving the step plate suspended over the stairwell. This creates a falling risk for users and may affect other similar installations.

Concerns summary This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists are insufficient, and no standardized risk classification system for swimming is in place.

Concerns summary Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin recovery training on specific light aircraft types for pilots.

Concerns summary Parachutes were not supplied for a light aircraft flight, and there is no mandatory spin recovery training specific to aircraft types, increasing risks during aerobatics.

Concerns summary Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his death.

Concerns summary Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for children playing near the water.

Concerns summary Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.