UK Inquiry Tracker

Steven Curtis

Historic (No Identified Response)

23 Jun 2015

Derbyshire Trading Standards Division

Product related deaths

Concerns summary (AI summary) There are safety concerns regarding Maplin N19KJ telescopic ladders, with 43,000 sold, warranting investigation into a potential catastrophic failure and the origin of the accident ladder.

Austen Harrison

All Responded

2015-0481 13 Apr 2015

Hugo Boss UK

Other related deaths

Concerns summary (AI summary) Basic health and safety training for managers, coupled with a lack of understanding of responsibilities and infrequent professional audits, led to undetected hazards like an unsafe mirror.

Action Taken (AI summary) Hugo Boss appointed a new Health and Safety Manager who undertook a detailed review of health and safety training, relaunched enhanced training for store and general managers via a workshop, and introduced a Health and Safety Management Workbook. Senior management also discuss health and safety trends and issues at quarterly review meetings.

Christopher Butler

All Responded

2015-0482 24 Feb 2015

Fire and Rescue Oxfordshire

Community health care and emergency services related deaths

Concerns summary (AI summary) A hidden electrical fault in boiler systems, potentially present in other similar properties, poses an undetected risk that standard electrical testing may miss. The Fire and Rescue Service needs to alert the community.

Action Planned (AI summary) The Fire and Rescue Service has undertaken a review of the circumstances, and plans to review their Near Miss and Fatal Incident Review process with Social Services and will share information with other fire and rescue services. They will also provide home electrical safety booklets and information, and have released a press release to raise awareness of electrical fire safety.

William Savage

Historic (No Identified Response)

18 Dec 2014

Ministry of Defence

Service Personnel related deaths

Concerns summary (AI summary) Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it was not. More detailed consideration is needed before removing threat warnings.

Kevin Lawrenson

All Responded

2014-0577 18 Dec 2014

Highways Agency

Road (Highways Safety) related deaths

Concerns summary (AI summary) Numerous accidents occurred due to inadequate and poorly visible signage for slow-moving vehicles. Improvements such as larger signs, lane separation, or electronic warnings are needed at this location.

Action Planned (AI summary) National Highways has instructed UK Highways M4O Limited to improve signing on the southbound approach to the Stokenchurch Cutting, including an additional 'Slow Moving Lorries' sign, raised sign height, and high visibility backing boards, with completion expected this summer.

Suzanne Cammell

Partially Responded

2014-0579 28 Jul 2014

Thames Valley Police Gloucestershire Constabulary

Police related deaths

Concerns summary (AI summary) Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.

Noted (AI summary) Thames Valley Police reviewed the communication between their control room and Gloucestershire Police regarding the deceased. They clarified the information that was shared and noted that Gloucestershire Police had previous knowledge of the deceased's mental health issues. They have also put measures in place to address information sharing between the Professional Standards Department and the officer who prepared the report.

Marcin Stoga

All Responded

2014-0576 21 Jul 2014

HMP Bullingdon

State Custody related deaths

Concerns summary (AI summary) Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.

Action Planned (AI summary) HM Prison and Probation Service is trialling revised Prisoner Escort Records including a 'Red Flag' page to highlight key risk/vulnerability information. They also highlight existing protocols for screening prisoners returning from court for healthcare or self-harm issues.

John Cook

All Responded

2014-0578 9 Jun 2014

NHS England

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Inadequate design and management of DNA CPR forms, including unclear validity wording and lack of clear hospital identification, caused significant confusion and communication failures.

Disputed (AI summary) NHS England will not add telephone numbers to DNA CPR forms, but highlights existing policy requiring specific review dates and clear cancellation procedures and has requested the CCG to share audit results and hold the Trust to account in relation to learning from the inquest; furthermore NHS England will write to all provider Trusts and CCGs to ensure they have adopted the DNACPR policy from NHS South of England.

Peter Norman Nott

All Responded

2014-0229 28 Feb 2014

Rush Court Nursing Home

Care Home Health related deaths

Concerns summary (AI summary) Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.

Action Taken (AI summary) Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale and be incorporated into resident care plans; only a registered nurse or person in charge can handover clinical information to paramedics.

Clive Gould

All Responded

2013-0357 16 Dec 2013

South Central Ambulance Service NHS Fou…

Community health care and emergency services related deaths

Concerns summary (AI summary) Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.

Action Taken (AI summary) South Central Ambulance Service has extended Rapid Response Vehicle cover to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. Rota match versus demand has also been reviewed. They have developed a Clinical Support Desk (CSD) within Emergency Operations Centre to support patients with clinical advice until a response is on scene.

David Selman

Historic (No Identified Response)

2013-0354 25 Sep 2013

South Central Ambulance Service

Community health care and emergency services related deaths

Concerns summary (AI summary) An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.