Other related deaths

Concerns summary A disused railway bridge is easily accessible to the public, including children, and no steps have been taken to prevent access despite its location next to a main road.

Concerns summary The hair colourant industry's reliance on "spontaneous reports" significantly underestimates allergic reactions to PPD, creating a massive disconnect with independent research on consumer safety.

Concerns summary Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.

Concerns summary There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.

Concerns summary Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.

Concerns summary Concerns exist regarding exposed, raised pipework, potentially attached to bridges, that is accessible to the public and may pose a safety risk.

Concerns summary Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.

Concerns summary An unguarded platform edge at a cafe, coupled with a slight incline, presents a serious fall hazard for patrons, particularly vulnerable individuals, which planning authorities failed to mitigate.

Concerns summary An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.

Concerns summary Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age restrictions and required adult supervision, differing from UK safety standards.

Concerns summary Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.

Concerns summary The building's design, featuring smooth concrete stairs without non-slip surfaces and no lobby to cushion falls, creates a serious risk of injury or death from impact with the external door.

Concerns summary Primary care lacks a clear framework and ready access to interpreters, and there is no system to flag relevant patient connections, impacting continuity of care.

Concerns summary Inadequate safety measures and insufficient warning signage at a dangerous weir and salmon chute put children playing in the area at significant risk.

Concerns summary Unsafe weir design lacks specific channels for kayaks and suitable upstream landing areas, coupled with insufficient warnings, risking water users' safety.

Concerns summary The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.

Concerns summary The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.

Concerns summary Delays in obtaining medical device data from manufacturers, inconsistent distribution of safety notices, and a lack of post-mortem analysis of medical devices hinder investigations and timely safety interventions.

Concerns summary Inadequate measures to treat ice in the car park created an unsafe environment.

Concerns summary Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.

Concerns summary An open front door created a wind tunnel, causing the back door of a public house to move forcibly and suddenly, leading to an accident.

Concerns summary Tour operator safety audits falsely indicated trained lifeguards and rescue equipment, with the lifeguard lacking child resuscitation skills, highlighting a critical gap between audit findings and actual safety provisions.

Concerns summary A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic safety switch also failed, exacerbated by vague guidance on safety device performance.

Concerns summary Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for mental health assessments, hindering timely risk identification and management for vulnerable patients.

Concerns summary Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.