UK Inquiry Tracker

Peter Lawrence

All Responded

2019-0245 1 Jul 2019

Walsall Mental Health Partnership Walsall Metropolitan Borough Council

Mental Health related deaths

Concerns summary Inadequate joint multi-disciplinary care planning and excessive reliance on a tribunal decision led to delayed responses to relapse indicators and insufficient follow-up for a patient with a history of disengagement.

David Squire

All Responded

2019-0062 25 Jan 2019

NHS England

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Concerns summary Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm to others.

Charlotte Tripper

All Responded

2018-0327 3 Oct 2018

National Express West Midlands

Road (Highways Safety) related deaths

Concerns summary A driver's unsafe practice of only looking straight ahead with minimal eye contact at junctions, to deter other drivers, indicates a systemic failure in safe driving training.

Christine Withers

All Responded

2018-0127 1 May 2018

Dudley NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating condition.

Natasha Ford

All Responded

2018-0052 13 Feb 2018

Cambian Group

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change prioritizing reduced restrictive practices.

Ronald Compson

All Responded

2018-0030 24 Jan 2018

Dudley Group NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Concerns included a possible system failure to contact a doctor, poor record-keeping regarding vomiting incidents, and inadequate communication with the family about an initial fall.

Penelope Benton

All Responded

2017-0349 30 Nov 2017

Dudley and Walsall Mental Health NHS Tr…

Mental Health related deaths Suicide (from 2015)

Concerns summary The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.

Philip Powell

All Responded

2017-0352 30 Nov 2017

Dudley Group NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.

Reginald Dixon

All Responded

2017-0214 18 Sep 2017

West Midlands Ambulance Service

Community health care and emergency services related deaths

Concerns summary An emergency call was incorrectly triaged, leading to a delayed response, compounded by insufficient resources and consistently slow ambulance attendance times, posing significant patient risks.

Dorothy Webb

All Responded

2017-0273 16 Aug 2017

Walsall Manor Hospital Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.

Aston Soulsby

All Responded

2017-0204 22 Jun 2017

Sandwell Local Authority

Child Death (from 2015) Road (Highways Safety) related deaths

Concerns summary Pedestrians waiting in hatched road areas and vehicles passing in these zones create confusion and significant risk of road traffic incidents.

Lily Townsend

All Responded

2017-0191 15 Jun 2017

Sandwell and West Birmingham Hospitals …

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.

Kenneth Evans

All Responded

2017-0175 30 May 2017

Dudley Group of Hospitals NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.

Sarah Poole

All Responded

2017-0176 30 May 2017

Royal Wolverhampton NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.

Beryl Farmer

All Responded

2016-0420 24 Nov 2016

Sandwell and West Birmingham Hospital N…

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.

Frank Mellers

All Responded

2015-0464 17 Nov 2015

Walsall Manor Hospital

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary There was a critical failure to communicate DNAR status with the family and between medical/nursing staff, leading to attempted resuscitation despite a DNAR order. Policies for DNAR issuance and communication require urgent review.

Ashley Matthews

All Responded

2015-0297 23 Jul 2015

British Transport Police

Railway related deaths

Concerns summary Insecure perimeter fencing allowed unauthorized access to the railway site, and there was a lack of warning signs for high voltage cabling on the bridge.

Tracey Bannister

All Responded

2014-0506 21 Nov 2014

Walsall Healthcare NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Patients discharged after ERCP surgery were not adequately advised to contact the surgical department directly for persistent symptoms, leading to delayed critical care.

Kirsty Pritchard

All Responded

2014-0565 17 Oct 2014

Black Country NHS Partnership Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.

Bridget Cahill

All Responded

2014-0266 11 Jun 2014

National Institute for Health and Clini…

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary A patient overdosed on morphine despite receiving less than the maximum prescribed dose, raising concerns about inadequate guidelines for dosage limits concerning body weight, co-morbidities, and drug accumulation in long-term therapy.

Arnold Soulsby

All Responded

2014-0241 28 May 2014

Department for Transport

Road (Highways Safety) related deaths

Concerns summary Current regulations do not mandate retrospective fitting of forward mirrors on lorries, leaving many vehicles without a crucial safety feature and increasing the risk of similar road deaths.

John Dodd

All Responded

2014-0145 2 Apr 2014

Dudley Group NHS Foundation Trust

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.

Jason Nock

All Responded

2014-0013 13 Jan 2014

Home Office

Alcohol, drug and medication related deaths

Concerns summary An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.

Action taken summary The Home Office has requested advice from the Advisory Council on the Misuse of Drugs and is actively collecting evidence on AH-7921. They are also leading an expert panel review …