UK Inquiry Tracker

Frederick White

Partially Responded

2015-0212 3 Jun 2015

Care Quality Commission Dudley Group NHS Foundation Trust West Midlands Ambulance Service NHS Tru…

Community health care and emergency services related deaths

Concerns summary (AI summary) There was a significant delay in diagnosing and managing a suspected spinal cord injury, including an initial failure to immobilise the patient and inadequate assessment during the hospital triage process.

Action Taken (AI summary) The Dudley Group NHS Foundation Trust, after an internal investigation, strengthened the criterion regarding older adults in Step Four triage. The West Midlands Ambulance Service Foundation Trust (WMASFT) has liaised with the regional trauma network to establish an elderly trauma working group to identify pre-hospital issues and provide advice.

Eliza Bowen

Historic (No Identified Response)

2015-0160 22 Apr 2015

Bilbrook Medical Centre Springfield House Care Home

Care Home Health related deaths

Concerns summary (AI summary) A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications of evolving diabetes despite a previous raised reading.

Anne Fowler

Historic (No Identified Response)

2015-0104 19 Mar 2015

Home Office

Other related deaths

Concerns summary (AI summary) Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.

Stanley Ward

Historic (No Identified Response)

2015-0045 5 Feb 2015

Care Quality Commission Lapal House and Lodge Care Home

Care Home Health related deaths

Concerns summary (AI summary) Care staff lacked awareness of increased bleeding risks for warfarin patients after falls. The facility also lacked clear policies or training for managing falls in anti-coagulant patients and for escalating concerns.

Tracey Bannister

All Responded

2014-0506 21 Nov 2014

Walsall Healthcare NHS Trust

Hospital Death (Clinical Procedures and medical management) related deaths

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

Action Taken (AI summary) Walsall Healthcare NHS Trust revised the ERCP discharge leaflet to include clear instructions for patients to contact the department where surgery was performed if symptoms of pain or raised temperature continue for more than 24 hours. The revised leaflet has been approved by the Endoscopy Steering Group, shared with all staff, and is now in use.

Lorraine Sheridan

Historic (No Identified Response)

2014-0496 12 Nov 2014

Sandwell Metropolitan Borough Council

Road (Highways Safety) related deaths

Concerns summary (AI summary) Lack of adequate pedestrian signalisation at a specific road location, specifically an audible phase indication, has contributed to multiple collisions.

Beryl Walters

Historic (No Identified Response)

2014-0489 11 Nov 2014

College of Emergency Medicine National Institute for Clinical Excelle…

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.

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 (AI 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.

Action Planned (AI summary) A protocol has been developed to ensure that if telephone contact cannot be established with a service user assessed to be in immediate risk of harm or death within 30 minutes, the CHTT are to carry out a cold call of the service user’s home address/ last known location within 1 hour, and if they still cannot gain access or locate the service user they are to contact the police to conduct a ‘safe and well’ check.

Nadine Thurman

Historic (No Identified Response)

2014-0303 31 Jul 2014

Dudley and Walsall NHS Mental Health Tr…

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) The psychiatric assessment was flawed due to a relative being excluded and the patient being inappropriately prompted about solitary assessment.

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 (AI summary) The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting attention be given to the maximum recommended dose and factors influencing morphine buildup in the body.

Noted (AI summary) The MHRA reviewed the post-mortem report and the pharmacokinetics/dynamics of morphine, concluding that the case does not prompt a review of the maximum permitted dose or a need to adjust it based on body weight or co-morbidities. They emphasize the importance of careful titration and review of opioid dosing, as recommended in current treatment guidelines.

Arnold Soulsby

All Responded

2014-0241 28 May 2014

Department for Transport

Road (Highways Safety) related deaths

Concerns summary (AI 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.

Action Planned (AI summary) The Department for Transport has asked officials to prepare a consultation about retro-fitting forward-facing mirrors on heavy goods vehicles first registered before 26 January 2007. The consultation will explore the potential benefits and costs associated with requiring retro-fit of these mirrors.

Sukbir Singh Rana & Mandip Singh

Historic (No Identified Response)

2014-0191 30 Apr 2014

Sandwell Metropolitan Borough Council

Road (Highways Safety) related deaths

Concerns summary (AI summary) The appropriateness of a 60 MPH speed limit on a bending country lane with limited lighting is questioned, as the maximum theoretical safe speed for the bend is also 60 MPH.

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

Action Planned (AI summary) The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review, and the electronic clinical information system will be reconfigured to create a visible alert to the consultant in charge when a patient's vital signs fall outside normal parameters.

Bertram Hamilton

Historic (No Identified Response)

2014-0080 26 Feb 2014

Nursing and Midwifery Council

Other related deaths

Concerns summary (AI summary) The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood sugars were so low.

Jason Nock

All Responded

2014-0013 13 Jan 2014

Home Office

Alcohol, drug and medication related deaths

Concerns summary (AI 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 Planned (AI summary) The Home Office has asked the Advisory Council on the Misuse of Drugs (ACMD) for advice on AH-7921 and is collecting evidence from health organizations and law enforcement. They are also undertaking a review of the UK's response to new psychoactive substances.

Lucy Kilvert

Historic (No Identified Response)

2013-0266 21 Oct 2013

National Institution for Health and Cli…

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.

John James Jackson

Historic (No Identified Response)

2013-0260 16 Oct 2013

Department of Health and Social Care

Product related deaths

Concerns summary (AI summary) The coroner notes a lack of readily available information about the dangers of consuming large quantities of caffeine, particularly from 'Hero Energy Mints', which are advertised as an alternative to energy drinks.