Other related deaths

Concerns summary A vulnerable, elderly patient was not provided with clear documented instructions to resume crucial anti-coagulation medication post-discharge, highlighting a gap in discharge advice for at-risk individuals.

Concerns summary A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying and escalating health and safety issues.

Concerns summary Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for hazards, and failing to provide lifejackets.

Concerns summary Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a pilot in distress.

Concerns summary Inconsistent care records and a senior manager's under-appreciation of a vulnerable patient's choking risk led to inadequate preventative measures, endangering other service users.

Concerns summary Unsafe unloading practices using an incompatible pallet truck and heavy loads on tailgates persist without review, despite previous warnings, creating a significant risk of falls and fatal injuries.

Concerns summary Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed assessment due to assumptions about substance misuse.

Concerns summary Elevated carbon monoxide levels, likely from faulty heating or ventilation, pose a continuing risk to life at the property. The source of the carbon monoxide toxicity remains unascertained.

Concerns summary Failures include inadequate exploration of risks, no referral to substance misuse services, and an uncoordinated inpatient discharge violating policy. Premature discharge from community treatment lacked engagement and proper care coordination.

Concerns summary A deficiency in the regulatory framework means vulnerable persons in supported HMOs are not protected from scalding risks, as no regulatory body assesses or requires thermostatic controls, unlike other health and social care settings.

Concerns summary Double doors and glazing at the bottom of stairs in Conservative Clubs are non-compliant with current health and safety regulations, and their proximity to stairs poses a significant risk.

Concerns summary The lack of regulation for residential homes housing vulnerable 18-21 year olds leads to providers with inadequate training and staffing. Additionally, there is no standard referral form, risking missed vital information for supported housing placements.

Concerns summary A driver's safety harness crotch straps detached due to the reinforcement plate failing during impact, raising concerns about the adequacy of current regulations and strength assessments for harness fitting points in cars.

Concerns summary A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting MAPPA professionals, posing a risk of future deaths.

Concerns summary Patient information for methotrexate lacks crucial warnings about the rare but serious side effect of phototoxicity, requiring a review of literature and adverse event reporting.

Concerns summary The patient experienced extreme delays in emergency department assessment and bed allocation, with multiple missed opportunities to recognize deterioration. This was attributed to systemic high demand on EDs, fueled by broader health and social care failures.

Concerns summary Patients with Protein S deficiency are not adequately informed about risk factors or routinely monitored, leaving them unaware of actions to mitigate thromboembolic risks.

Concerns summary Hostel workers lacked structured training to identify risks of alcohol intoxication and recognize the need for urgent medical intervention, creating significant safety gaps.

Concerns summary Staff lacked adequate training and recognition of choking risks for adults with autism and learning disabilities, leading to insufficient adherence to mealtime recommendations.

Concerns summary Clinical advice on weight-bearing status was unclear, and the hospital's VTE risk reduction policy for outpatients lacked clarity. There was also no documented evidence of information provided to the patient.

Concerns summary The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.

Concerns summary Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.

Concerns summary A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.

Concerns summary Privately rented accommodation in Wandsworth is at increased fire and CO risk due to the lack of mandatory smoke/CO detectors, as the borough has no registered landlord scheme or enforcement powers.

Concerns summary The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.