2013

Concerns summary (AI summary) The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.

Concerns summary (AI summary) The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.

Concerns summary (AI summary) Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.

Concerns summary (AI summary) An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.

Concerns summary (AI summary) Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.

Concerns summary (AI summary) A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons or smocks to residents who smoke to prevent similar incidents.

Concerns summary (AI summary) Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.

Concerns summary (AI summary) A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from a fence and shrubbery.

Concerns summary (AI summary) Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their home countries.

Concerns summary (AI summary) District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely take temperatures, as they were not issued with thermometers.

Concerns summary (AI summary) Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's warfarin levels after her move to a care home and new GP practice.

Concerns summary (AI summary) A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.

Concerns summary (AI summary) Vehicles leaving the carriageway and landing in a rhynne leads to death by drowning; however, retaining barriers may be too costly given the extent of roadway that would need protection.

Concerns summary (AI summary) The coroner requests consideration of specific measures to reduce road traffic injuries at or on the approach to a bend on the A19 at Owston.

Concerns summary (AI summary) The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.

Concerns summary (AI summary) The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be taken to prevent such occurrences.

Concerns summary (AI summary) A Root Cause Analysis Investigation Report identified a number of areas of concern arising from the investigation.