Other related deaths

Concerns summary District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when a patient's life was at risk.

Concerns summary An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river below.

Concerns summary Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack of multi-agency risk assessment. There were also significant communication breakdowns between mental health services and the police.

Concerns summary Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk of falls and potential death.

Concerns summary A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.

Concerns summary A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a future fall risk.

Concerns summary A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide their location to emergency services.

Concerns summary The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.

Concerns summary Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant issues to police.

Concerns summary Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.

Concerns summary A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.

Concerns summary Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.