2018

Concerns summary Pedestrians at a junction may be dangerously misled by a green light for an adjacent crossing, causing them to miss a red light prohibiting them from crossing the main road.

Concerns summary There is no legal requirement for quad bike riders to wear crash helmets, even on road-adapted vehicles, despite evidence suggesting a helmet could prevent fatal head injuries.

Concerns summary A lack of systemic communication between specialty consultants prevents identifying and documenting potential ongoing risks when patients receive simultaneous treatments from different departments.

Concerns summary Poor record-keeping for a detained mental health patient meant risks, leave rationale, and assessments were undocumented, hindering informed decision-making and continuity of care for staff.

Concerns summary The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.

Concerns summary Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting in death.

Concerns summary The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning of danger.

Concerns summary A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.

Concerns summary Concerns persist about sensor system outages failing to alert staff to falls and inadequate safeguards for residents prone to sliding in chairs.

Concerns summary Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.

Concerns summary An outdated and unreviewed isolation procedure from previous work led to an unsafe standard for new tasks, exacerbated by a lack of clear responsibility between contractors for safe isolation.

Concerns summary Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed escalation.

Concerns summary A lack of formal first aid training, including choking response, for volunteers, absence of emergency medical equipment, and insufficient oversight for child safeguarding were identified.

Concerns summary Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.

Concerns summary There is no legal requirement for care home carers to have first aid training or to carry mobile phones, posing a risk in emergency situations.

Concerns summary Routine testing for toxoplasmosis was not performed on stem cell transplant patients with infection signs, and local learning needs nationwide sharing.

Concerns summary Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.

Concerns summary A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying a pneumonia diagnosis.

Concerns summary The absence of a national registry for biliary stents creates a risk of "forgotten stents," while national guidelines lack a clear definition of "short-term" use.

Concerns summary Misconceptions about Mental Health Act procedures, withdrawal of care without welfare checks, and delays due to weekend scheduling and information requirements hampered a mental health assessment.

Concerns summary High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.

Concerns summary Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.

Concerns summary The response to an NHS 111 call was deemed wholly inadequate, raising concerns about emergency access to care.

Concerns summary Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.

Concerns summary Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.